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A  TEXT-BOOK 


DERMATOLOGY 


BY 


J.    DARIER 


PHYSICIAN  TO  THE  HOPITAL  SAINT-LOUIS,  MEMBER  OF  THE  ACADEMY  OF  MEDICINE,  PARIS, 
FRANCE  ;  HONORARY  MEMBER  OF  THE  AMERICAN  DERMATOLOGICAL  ASSOCIATION,  ETC. 


AUTHORIZED  TRANSLATION  FROM  THE  SECOND  FRENCH  EDITION 


Edited  with  Notes  by 

S.    POLLITZER 


NEW  YORK 

EX-PRESIDENT    OF    THE    AMERICAN    DERMATOLOGICAL    ASSOCIATION;     CORRESPONDING 

MEMBER  OF  THE  FRENCH  SOCIETY  OF  DERMATOLOGY  AND  SYPHILOGRAPHY,  ETC. 


ILLUSTRATED  WITH    204    ENGRAVINGS   AND 
4  COLORED   PLATES 


LEA  &   FEBIGER 

PHILADELPHIA    AND    NEW    YORK 
1920 


Copyright 

LEA  &   FEBIGER 

1920 


MAR  -4  1920 


g)CU559932 


PREFACE  TO  THE  SECOND  EDITION. 


The  first  edition  of  this  book  was  exhausted  several  years  ago. 
The  Great  War  for  some  time  absorbed  all  our  activities  and  all 
our  thoughts.  But  the  time  has  come  to  think  of  the  young  physi- 
cians returning  from  the  armies  and  make  ready  the  means  for 
facilitating  the  work  they  are  called  upon  to  perform.  I  have 
accordingly  prepared  this  second  edition,  in  spite  of  the  difficulties 
of  these  troublous  times.  I  have  insisted  upon  its  being  entirely 
abreast  of  the  progress  of  science  and  as  complete  as  possible 
without  unnecessary  details.  The  general  plan  of  the  book,  which 
has  been  tested  and  found  to  possess  real  didactic  advantages  has, 
of  course,  been  retained. 

Many  paragraphs  have  required  rewriting  and  more  or  less  con- 
siderable elaboration.  Among  these  may  be  mentioned  those  deal- 
ing with  anaphylaxis,  phagedena,  the  sarcoids,  the  gangrenes,  the 
cutaneous  atrophies,  inguinal  epidermophytosis  and  the  derm  ato- 
my coses.  The  review  of  the  general  interpretation  of  tubercu- 
losis, congenital  syphilis  and  the  xanthomata  has  had  to  undergo 
notable  modifications;  paragraphs  or  new  chapters  have  been  devoted 
to  the  dyskeratoses,  cutaneous  diphtheria,  the  leishmanioses,  the 
cutaneous  leukemias,  the  tophi  of  gout,  etc.  The  introduction  of 
the  serodiagnosis  of  syphilis  and  the  treatment  with  the  arseno- 
benzols  into  daily  practice  has  demanded  the  allotment  of  con- 
siderable space  to  these  subjects.  Finally,  in  rewriting  the 
therapeutic  notes,  I  have  endeavored  to  make  them  still  more 
practical  and  to  emphasize  the  recommendations  dictated  by  my 
personal  experience  as  to  the  choice  of  medication  and  the  errors 
to  be  avoided. 

Professor  Jadassohn,  of  Bern,  has  added  to  the  German  transla- 
tion of  this  book  which  appeared  under  his  direction  in  1913,  -a 
considerable  number  of  notes  which  I  have  carefully  retained  when- 


iv  PREFACE  TO   THE  SECOND  EDITION 

ever  his  suggestions  seemed  to  me  to  be  of  value  for  the  reader; 
they  have  been  incorporated  in  my  text,  of  course,  mentioning 
their  origin. 

As  it  stands,  this  volume  although  rejuvenated  and  somewhat 
better  nourished,  remains  essentially  the  same  as  its  predecessor. 
I  can  only  wish  that  it  may  meet  with  the  same  kind  reception. 
My  excellent  and  devoted  publishers  have  left  nothing  undone  to 
present  it  in  good  shape  and  I  herewith  express  to  them  my  sincere 
and   grateful  acknowledgments. 

J.  Darier. 


EDITOR'S  PREFACE. 


In  undertaking  the  task  of  editing  Darier's  Precis  de  Dermatologie 
I  have  been  actuated  less  by  a  personal  friendship  with  the  dis- 
tinguished author  extending  over  a  period  of  thirty  years,  than  by 
a  sense  of  the  importance  of  introducing  to  the  English-reading 
student  of  dermatology  a  work  that  is  in  many  respects  unique 
in  its  presentation  of  the  subject  and,  as  it  seems  to  me,  of  extra- 
ordinary value  for  the  student  and  the  teacher. 

The  plan  of  the  work  is  fully  explained  in  the  author's  introductory 
chapter  and  needs  no  further  comment.  The  German  translation 
of  the  first  edition  enjoyed  the  advantage  of  editorial  comment  at 
the  hands  of  one  of  the  foremost  dermatologists  of  our  time,  Pro- 
fessor Jadassohn  of  Berne,  and  Darier  has  made  use  of  these  com- 
ments in  this  the  second  edition  of  his  Precis.  In  preparing  the  work  for 
English  readers  I  have  added  notes  which  are  enclosed  in  brackets, 
[  ]  to  differentiate  them  from  the  author's  text  and  which,  in 
the  case  of  more  extensive  notes,  are  printed  in  a  different  style  of 
type.  It  need  not  be  emphasized  that  they  are  not  intended  by 
way  of  criticism:  a  few  of  them  seemed  to  me  desirable  for  the 
elucidation  of  the  text;  some  were  suggested  by  conditions  peculiar 
to  English  and  American  practice  and  some  convey  my  personal 
experience  in  clinical  dermatology.  It  can  hardly  be  expected  that 
two  dermatologists  practicing  their  profession  for  thirty  years  in 
different  hemispheres  will  be  of  the  same  mind  on  all  subjects. 

There  is  no  dearth  of  excellent  treatises  of  dermatology  in  the 
English  language  and  this  work  may  confidently  be  expected  to  find 
its  place  beside  them.  The  student  cannot  fail  to  profit  from  a  study 
of  Darier's  unusual  power  of  delineation  in  brief  compass,  his  pre- 
sentation of  clear-cut  cameos  of  description,  his  obvious  habit  of 
thinking  of  lesions  in  relation  to  their  anatomical  structure  and 
always  with  a  background  of  general  pathology.    To  these  sufficient 


VI  EDITOR'S   PREFACE 

reasons  for  producing  another  book  may  be  added  the  author's 
originality  in  the  arrangement  of  his  subject-matter  and  finally 
the  desirability  of  placing  before  English-reading  students  the  views 
of  a  foreign  author,  especially  one  who  represents  an  old  and  honored 
school  of  dermatology. 

French  dermatologists  have  played  a  leading  role  in  the  devel- 
opment of  our  science.  The  Hopital  Saint-Louis,  the  greatest 
dermatological  clinic  in  the  world,  has  afforded  an  extraordinary 
opportunity  for  study  and  for  more  than  a  century  it  has  furnished 
a  succession  of  great  dermatologists  who  have  handed  down  their 
experience  from  teacher  to  pupil  in  an  unbroken  chain.  Berne, 
Berlin,  Breslau,  Hamburg,  London  and  many  cities  in  America  and 
elsewhere  have  excellent  dermatologists  whose  observations  and 
studies  have  greatly  enriched  our  science;  but  in  all  these  centers, 
dermatology  is  the  work  of  one  man  or  of  a  number  of  independent 
units.  Vienna  indeed  furnishes  an  example  of  a  school  of  derma- 
tology that  has  exercised  a  powerful  and  lasting  influence  in  its 
field,  lint  Vienna  was  a  one-man  school  and  unfortunately  the 
great  light  shed  by  Ilebra  so  blinded  his  followers  that  for  a  gen- 
eration the  Vienna  school  suffered  from  a  form  of  dermatological 
amblyopia:  neither  Duhring's  disease,  for  instance,  nor  pityriasis 
rosea  were  recognized  in  Vienna  as  dermatological  entities.  French 
dermatology  is  unique  in  the  peculiar  circumstance  of  a  familiarity 
with  the  great  masters  of  the  past  that  is  almost  personal.  Alibert, 
Cazenave,  Biett,  Devergie,  Bazin,  Vidal,  Fournier,  Besnier,  seem 
living  personalities  to  the  present-day  student  at  the  Saint-Louis. 
The  advantages  derived  from  this  local  continuity  of  observation 
and  practice  are  inestimable. 

There  is,  however,  an  inherent  danger  bound  up  with  its  advan- 
tages; that  is  the  danger  of  falling  to  too  great  an  extent  under  the 
influence  of  tradition.  Forty  years  ago  French  dermatology  was 
suffering  from  the  defects  of  its  merits  and  it  is  only  recently  that 
such  conceptions  as  are  implied  in  the  terms  herpetism,  arthritism, 
lynipliatism,  etc.,  have  ceased  to  sway  French  dermatological 
thought  and  traces  of  these  conceptions  still  linger  in  French 
medical  literature,  side  by  side  with  the  most  advanced  thought  in 
medical  science. 

Another  possible  effect  of  tradition  may  be  found  in  the  current 


EDITOR'S  PREFACE  Vll 

French  dermatotherapy.  French  physicians  to  a  great  extent 
are  in  the  habit  of  employing  elaborate  and  complicated  formulas 
in  their  treatment  of  diseases.  Most  of  these  have  the  sanction  of 
long  usage;  some  of  them  are  even  medieval  in  their  construction. 
French  dermatologists  probably  have  not  less  success  in  curing 
their  patients  than  those  of  other  countries  and  it  is  surely  not  less 
interesting  than  instructive  to  learn  that  there  are  various  ways  of 
accomplishing  this  result. 

The  observant  reader  will  be  struck  with  the  great  preponderance 
of  references  to  achievements  of  French  dermatologists.  The 
assumption  that  this  is  an  illustration  of  a  narrow  spirit  which  is 
out  of  place  in  a  scientific  work  will  be  dispelled  if  the  reader  will 
examine  an  English,  American,  German  or  Italian  text-book  from 
the  same  point  of  view.  He  will  find  that  this  form  of  Chauvinism 
is  common  to  all  nations  and  is  indeed  perfectly  natural.  An  author 
obviously  will  cite  the  literature  with  which  he  is  most  familiar 
and  which  is  most  accessible  to  his  readers.  From  this  point  of  view 
again  it  is  an  advantage  to  the  English  reader  to  become  acquainted 
with  the  work  of  a  foreign  author  and  thereby  acquire  a  broader 
outlook  on  his  specialty. 

The  Editor  ventures  to  express  the  hope  that  this  work  of  Darier's 

will  be  found  not  less  useful  to  the  reader  than  it  has  been  instructive 

and  inspiring  to  him. 

S.  Pollitzer. 
New  York,  1920. 


CONTENTS. 


Introduction 17 

Morphology  of  the  Dermatoses 17 

Nosography  of  the  Dermatoses 20 

Therapeutic  Notes 20 


PART  I. 
MORPHOLOGY  OF  THE  DERMATOSES. 

CHAPTER  I. 

Erythema  and  the  Erythemata 23 

Intertrigo 30 

Erythema  Solare  seu  Actinicum 32 

Erythema  Pernio  or  Frost-bite 34 

Acro-asphyxia  and  Livedo 36 

Rosacea 36 

Erythema  Multiforme 39 

Syphilitic  Roseola 41 

CHAPTER  II. 

Urticaria 43 

Giant  Urticaria 49 

Urticaria  Factitia,  or  Dermographism 49 

CHAPTER  III. 

Purpura 52 

Secondary  Purpuras 54 

Primary  Purpuras 54 


CONTENTS 


CHAPTER  IV 


Eczema (,0 

•     -      •   • 79 


Artificial  Eczemas 
Infantile  Eczemas 

Secondary  Eczematization §2 

Eczematosis go 

Dysidrosis gc 

Acute  Disseminated  Eczema  or  Miliary  Impetigo      ....  87 


CHAPTER  V. 


Eczematides 


El{YTHEMATOTTS-SQUAMOUS    DERMATOSES       ....  S9 


102 


Pityriasis  Rosea  of  Gibert 

Psoriasis 

Parapsoriasis ,ji 

Psoriatiform  Syphilides ijq 

Erythemato-squamous  Epidermo-mycoses 114 


CHAPTER  VI. 

Erythrodermas H5 

Primary  Erythrodermas Hg 

Erythrodermic  Dermatoses J20 

Secondary  Erythrodermas 12i 

<  fcragenital  Erythrodermas  and  Erythrodermas  of  the  Newborn  122 


CHAPTER  VII. 

Papules  and  Papulae  Dermatoses  ....     127 

Juvenile  Mat  Warts j.,q 

Ldcherj  Planus ,o. 

Atypical  Forms  of  Lichen  Planus yi-j 

Papules  of  Prurigo 140 

Papular  Syphilides I  e> 

Lichen  Scrofulosorum j.r 


chapter  viii. 

Vesicles  and  Vesicular  Dermatoses     .     .  148 

HerPes '.  150 

Z,,n:i 154 


CONTENTS 


CHAPTER  IX. 

Pustules  and  Pustular  Dermatoses      ....  160 

Impetigo 162 

Ecthyma 169 

Pustules  of  the  Infectious  Chronic  Dermatoses 172 

CHAPTER  X. 

Bullae  and  Bullous  Dermatoses 174 

Accidentally  Bullous  Dermatoses 175 

Bullous  Impetigos 178 

Pemphigus  Acutus  Febrilis  Gravis 179 

Recurrent  Pemphigus,  Duhring's  Disease  or  Polymorphous  Dermatitis     .  179 

Rare  Dermatoses  Related  to  Duhring's  Disease 184 

Chronic  Pemphigus 186 

Pemphigus  Foliaceus 189 

Congenital  Pemphigus 191 

Pemphigus  Hystericus 192 

CHAPTER  XL 

Keratoses 194 

Kerosis 196 

Pityriasis  Simplex 19S 

Ichthyosis 200 

Ichthyosiform  Hyperkeratoses 203 

Circumscribed  Keratoses 206 

Keratoderma 211 

Keratosis  of  Mucous  Membranes .      .      .218 

Dyskeratoses 230 

CHAPTER  XII. 

Papillomatous  and  Proliferating  Dermatoses  .      .      .  237 

Venereal  Warts 238 

Verruca  Vulgaris 240 

Papillary  and  Pigmentary  Dystrophy  or  Acanthosis  Nigricans       .      .      .  242 

Accidentally  Proliferating  Dermatoses 244 

Proliferating  Tropical  Dermatoses 249 

CHAPTER  XIII. 

Tubercles  and  Tuberculo-ulcerative  Dermatoses       .      .  252 

Tuberculo-Ulcerative  Dermatoses 253 

Tubercular  Sypbilides 253 

Lupus  Tubercles 256 

Tubercles  of  Leprosy 258 

Cutaneous  Sarcoids  or  Lupoid 259 


301 


CONTENTS 


CHAPTER  XIV. 

Nodes  and  Nodules 263 

Nodular  Dermatoses 263 

leute  Nodular  Dermatoses 265 

Gummas 266 

Subacute  Non-gummous  Nodes 271 

Sarcoids 272 


CHAPTER  XV. 

In  i  rations,  Ulcerative  Dermatoses  and  Cutaneous  Gangrenes  277 

Ulceration  in  General 277 

Acute  Ulcerations 281 

Subacute  Ulcerations 284 

Phagedena 293 

Ulcers 296 

Ulcerations  of  Mucous  Membranes 303 

Cutaneous  Gangrene 312 

CHAPTER  XVI. 

Dyschromias 320 

Artificial  ami  Secondary  Dyschromias 321 

Associated  Dyschromias  or  Dyschromic  Dermatoses 323 

Pigmentary  Spots 323 

Diffuse  Dyschromias  and  Melanodermas 325 

Vitiligo 329 

Tattoo  Marks  and  Argyria 332 


CHAPTER  XVII. 


Ci  i  wi.ni  -  Atrophies,  Scleroses  and  Dystrophies 

<  Beatrices 

Linear  and  Macular  At  rophies 
Idiopathic  Atrophies 
Sclerotic  Atrophies  in  Spots 

Scleroderma 

Regional  Atrophies  and  I  termatoscleroses 
( lutaneous  I  dystrophies 


334 
336 
341 
343 
346 
347 
353 
355 


CHAPTER  XVIII. 

Cutaneous  Hypertrophies 360 

Elephantiasis  • 361 

Non-elephantiastic  Hypertrophies 371 


CONTENTS 


CHAPTER  XIX. 

Folliculoses 376 

Acute  Suppurative  Folliculitides 377 

Seborrhea 383 

The  Acnes 384 

Cicatricial  Depilating  Folliculitides 392 

Subacute  Folliculitides 395 

Pityriasis  Rubra  Pilaris 399 

Follicular  Keratosis 401 


CHAPTER  XX. 

Trichoses 404 

Hypertrichoses 404 

Alopecias 407 

Dystrophic  Trichoses • 416 

Parasitic  Trichoses 419 

Trichomycoses 428 


CHAPTER  XXL 

Onychoses 430 

CHAPTER  XXII. 

HiDROSES 441 

Functional  Hidroses 442 

Organic  Hidroses 445 


PART  II. 
NOSOLOGY  OF  THE  DERMATOSES. 


CHAPTER  XXIII. 

Artificial  Dermatitides      ......  447 

Dermatitides  Due  to  Mechanical  Causes 448 

Dermatitides  Due  to  Physical  Causes 450 

Toxidermas 456 

Toxidermas  from  External  Causes        463 

Toxidermas  from  Internal  Causes 471 


CONTENTS 


CHAPTER  XXIV 


Neurodermatoses:  Pruritus  and  Prurigo 481 

Primary  Pruritus        483 

Prurigo 488 


CHAPTER  XXV. 

Parasitic  Dermatoses 502 

Dermatoses  Caused  by  Insects 502 

Dermatoses  Caused  by  Acari  (Mites) 507 

Dermatoses  Caused  by  Worms  and  Larvae 514 

Epklennoiiiycosos 515 


CHAPTER  XXVI. 

[nfectious  Dermatoses — Pyodermatitides              .      .      535 
Pyodermatitides 536 


CHAPTER  XXVII. 

Infectious  Bacillary  Dermatoses 546 

Tuberculosis 546 

Leprosy 578 

Glanders 590 

Verruga  Peruana 593 

Anthrax     Malignant  Pustule 593 

( Cutaneous  Diphtheria 594 

Soft  Chancre 596 


CHAPTEB  XXVIII. 

Dermatomycoses 599 

Actinomycosis 599 

.Mycetoma  or  Madura    loot  602 

Blastomycoses 603 

Sporotrichoses 605 


CHAPTEB  XXLX. 

l.\Ki:cTiors   Dermatoses  due  to  Protozoa       .      .      .  610 

Syphilis 610 

Yaws 646 

Leishmanioses 648 


CONTENTS 


CHAPTER  XXX. 


Dermatoses  of  Leukemias  and  Analogous  Pathological  Conditions    651 

Cutaneous  Leukemias 651 

Mycosis  Fungoides 657 


CHAPTER  XXXI. 

Tumors  of  the  Skin 663 

Nevi 664 

Epithelial  Tumors 669 

Vascular  and  Connective-tissue  Tumors 689 

Sarcoma 706 


APPENDIX. 

Therapeutic  Notes 711 


DISEASES  OF  THE  SKIN. 


INTRODUCTION. 

This  book  is  destined  for  new  students  entering  a  dermatological 
service  and  for  general  practitioners  whose  hospital  recollections 
have  become  somewhat  indistinct.  My  object  has,  therefore,  been 
to  make  it  as  concise  and  practical  as  possible,  while  including  the 
entire  domain  of  cutaneous  pathology.  In  order  to  make  it  short, 
I  have  been  obliged  to  sacrifice  the  entire  bibliography,  historical 
references,  quotations,  learned  discussions,  etc.,  limiting  myself  to 
the  essential  data  from  the  standpoint  of  diagnosis  and  treatment. 
In  order  to  make  it  practical,  it  has  seemed  to  me  desirable  to 
arrange  the  material  according  to  a  plan  which  is  not  customary 
and  which  I  must  first  explain  and  justify. 

MORPHOLOGY   OF   THE   DERMATOSES. 

In  the  first  part  (Chapters  I  to  XXII)  the  eruptive  lesions  and 
the  non-eruptive  cutaneous  changes,  namely,  the  elementary  derma- 
tological forms  are  discussed  and  to  each  of  these  a  description  of 
the  principal  syndromes  in  which  the  elementary  forms  occur  is 
added.  This  requires  some  explanation.  In  dermatological  prac- 
tice, the  physician  is  confronted  by  very  peculiar  conditions.  He 
does  not  have  to  look  for  pathological  symptoms  with  the  help  of 
more  or  less  complicated  devices;  the  symptoms  present  themselves 
directly;  he  recognizes  their  features  and  their  localization  at  once 
and  witnesses  this  development.  Under  these  conditions  it  seems 
obvious  to  me  that  a  book  intended  to  facilitate  the  study  of  skin 
diseases  should  accord  the  first  place  to  morphology,  namely,  to 
what  can  be  seen.  In  regard  to  the  visible  manifestations  of  cutan- 
eous pathology,  two  contingencies  are  possible:  the  condition  may 
be  an  eruptive  dermatosis,  or  the  dermatosis  under  consideration 
may  be  non-eruptive. 

A.  Eruptive  Dermatoses. — This  term  is  applied  to  skin  diseases 
made  up  of  efflorescences,  namely,  spots,  papules,  vesicles,  etc. 
The  analysis  of  every  eruptive  dermatosis  must  take  up  succes- 
2 


IS  DISEASES  OF  THE  SKIN 

sively  four  orders  of  facts:    those  relating  to  the  efflorescence,  to 
the  eruption,  to  the  disease  and  to  the  patient. 

1.  The  eruptive  lesion  deserves  attention  in  the  first  place.  This 
is  in  reality  merely  the  anatomical  lesion  of  the  dermatosis  as  it 
appears  to  the  naked  eye.  To  inspect  attentively  an  efflorescence, 
to  palpate  it,  to  scratch  it,  to  compress  it  under  a  glass  slide, to 
prick  it  with  a  needle  so  as  accurately  to  determine  its  type — this 
constitutes  in  a  general  way  the  naked-eye  study  of  the  pathological 
anatomy.  Conversely,  it  may  be  stated  that  to  subject  the  efflores- 
cence to  biopsy  for  the  purpose  of  studying  its  histology  means  its 
clinical  examination  under  the  microscope. 

The  efflorescences  are  of  fundamental  importance;  they  really 
represent  the  dermatologist's  alphabet  and  no  one  ignorant  of  them 
can  learn  to  read  the  skin. 

2.  The  eruption  represents  the  efflorescences  taken  as  a  whole. 
It  is  visible  and  all  its  features  are  in  evidence;  it  is  necessary  to 
note  its  abundance,  its  dissemination  or  its  confluence,  its  topo- 
graphical distribution,  etc. 

An  eruption  is  said  to  be  simple  or  pure  when  it  is  formed  of 
lesions  of  the  same  kind  and  of  the  same  degree  of  development;  it 
is  described  as  deformed,  when  the  lesions  are  in  different  stages  of 
evolution;  it  is  called  complex  or  polymorphous  when  it  is  made  up 
of  lesions  of  various  types;  complicated,  when  the  primary  lesions 
become  associated  with  other  lesions  secondary  and  of  another  kind. 

:!.  Information  concerning  the  disease  is  usually  furnished  by 
inquiry;  it  is  necessary  to  ask  about  the  mode  of  onset,  the  preced- 
ing or  accompanying  circumstances,  the  extracutaneous  symptoms, 
the  course,  etc.  Direct  examination,  however,  will  often  permit  a 
series  of  data  to  be  secured  in  this  connection  which  will  forestall  the 
patient's  answers  and  serve  to  control  their  accuracy. 

I.  Among  the  conditions  peculiar  to  the  patient,  some  are  of  an 
objective  kind;  for  example,  the  sex,  the  age,  the  race  and  the  con- 
stitution of  the  individual.  Information  must  also  be  obtained 
in  regard  to  his  occupation,  his  hereditary,  hygienic  and  pathologi- 
cal antecedents,  etc.;  the  viscera,  body  fluids  and  functions  must  be 
reviewed;  briefly,  a  general  clinical  examination  be  carried  out  in 
order  to  ascertain  the  nature  of  the  soil  on  which  the  skin  disease 
develops. 

B.  Non-eruptive  Dermatoses.-  In  a  second  group  of  cases  the 
physician  is  not  confronted  with  an  eruption.  The  cutaneous 
alterations  may  consist,  for  example,  of  a  change  in  color  of  the 
skin,  or  dyschromia;  in  hypertrophy  or  atrophy;  in  a  lesion  of  the 
nails,  the  hairs,  etc. 

This  altered  appearance  of  the  integuments  can  sometimes  be 
referred  with  a  high  degree  of  probability  to  a  definite  inflamma- 


INTRODUCTION  19 

tory,  degenerative  or  dystrophic  pathological  process.  In  other  cases, 
however,  it  is  impossible  to  determine  the  nature  of  the  process. 
It  therefore  seems  preferable  to  me  to  depend  on  what  can  be  seen 
and  to  restrict  oneself  to  classifying  the  pathological  condition  as 
it  exists,  instead  of  venturing  into  the  ever-fluctuating  domain  of 
general  pathology. 

The  apparently  extremely  variable  morphology  of  skin  diseases 
can  thus  be  brought  down  to  various  forms  of  eruptive  lesions  on  the 
one  hand  and  of  pathological  conditions  of  the  skin  on  the  other. 
I  have  combined  them  all  under  the  name  of  elementary  dermato- 
logical forms.  For  the  description  of  dermatoses  on  the  bases  of 
their  morphology,  my  work  thus  becomes  reduced  to  the  following: 

Selection  of  a  certain  number  of  elementary  forms,  easily  dis- 
tinguished or  recognized  after  very  little  study;  description  of  these 
forms  as  accurately  as  possible,  indicating  the  special  anatomical 
lesions  from  which  they  result. 

Next,  in  view  of  the  fact  that  these  dermatological  forms  may  be 
encountered  in  various  cutaneous  affections,  it  still  remains  to  take 
up  these  affections  one  by  one  and  to  show  what  constitutes  their 
individuality  and  on  what  their  diagnosis  is  based. 

The  dermatological  types  and  cutaneous  affections  which  can  be 
approximated  on  the  basis  of  their  morphology  are  certainly  not 
pathological  varieties  or  diseases  in  the  nosographic  sense  of  the 
word,  but  are  simple  syndromes.  Now  these  syndromes  are  of  two 
different  kinds.  Some  have  an  unknown  or  complex  etiology 
(example:  psoriasis);  when  they  have  been  described  with  all  their 
features,  there  is  nothing  more  to  be  said.  Others  on  the  contrary 
are  referable  to  a  known  specific  cause  (example:  psoriatiform 
syphilides)  and  constitute  one  of  the  possible  manifestations  of  a 
definite  disease.  The  latter  will  have  to  be  referred  to  again  in 
the  second  part  of  this  book  and  given  their  proper  place  under  the 
general  description  of  this  disease. 

The  first  twenty-two  chapters  are  accordingly  dedicated  to  the 
principal  elementary  dermatological  forms  and  to  the  syndromes 
derived  from  them. 

A  classification  of  cutaneous  diseases  on  the  basis  of  their  mor- 
phology presents  this  great  advantage  that  the  question  of  the 
diagnosis  is  presented  under  the  same  form  in  which  it  is  met  in 
dermatological  practice.  On  the  other  hand,  it  is  open  to  two 
principal  objections.  The  first  is  this,  that  an  attempt  to  take 
into  account  all  the  eruptive  forms  to  which  the  same  disease  can 
give  rise,  would  necessarily  involve  the  splitting  of  its  description 
into  very  many  fragments.  In  order  to  avoid  this  difficulty,  I 
have  restricted  myself  in  the  first  part  to  dwelling  upon  the  most 
common  and  most  characteristic  syndromes;  the  others  are  briefly 


20  DISEASES  OF   THE  SKIN 

mentioned  so  as  to  warn  the  reader  against  a  possible  mistake; 
their  description  will  follow  in  the  second  part  of  this  book. 

The  other  objection  is  that  an  arrangement  based  simply  on 
clinical  appearances  can  in  no  way  constitute  a  classification.  It 
lot-  not  claim  to  do  so.  Nobody  would  think  nowadays  of  renew- 
ing the  attempts  of  Plenke  and  Willan.  It  is  generally  conceded 
that  the  only  logical  and  scientific  classification  in  dermatology  as 
well  as  in  other  branches  of  pathology  is  that  which  is  based  on 
etiology. 

NOSOGRAPHY  OF  THE  DERMATOSES. 

In  the  second  part  (Chapters  XXIII  to  XXXI)  the  point  of  view 
is  entirely  different.  There  I  review  the  diseases  of  the  skin  itself, 
the  pathological  entities  with  a  definite  etiology,  classified  according 
to  the  nature  of  their  cause.  Hence  there  will  be  found:  artificial 
dermatoses,  'parasitic  dermatoses,  infections  dermatoses,  etc. 

I  have  put  into  this  class  a  group  of  skin  diseases  united,  if  not 
by  a  first  common  cause,  at  least  by  an  identical  phenomenon  of 
;i  general  nature,  namely,  essential  pruritus,  dependent  upon  a 
nervous  disturbance;  this  appears  to  be  the  second  cause  of  the 
cutaneous  manifestations.  This  group  can  be  designated  under  the 
name  of  pruritus  or  neurodermatoses. 

I  finally  group  among  the  pathological  entities  the  tumors  of  the 
shin;  admitting  that  in  doing  so  I  conform  with  custom  rather  than 
follow  a  personal  conviction.  The  etiology  of  the  majority  of 
tumors  is  unknown  or  theoretical;  it  is  for  this  reason  no  less  than 
on  account  of  their  morphology  and  course  that  they  have  hitherto 
been  considered  as  forming  a  natural  group. 

The  etiological  classification  of  skin  diseases  is  confronted  with 
an  insuperable  difficulty.  There  exists  a  series  of  eruptions,  by  no 
means  very  rare  or  imperfectly  characterized  (for  example,  eczema, 
lichen,  psoriasis)  the  etiology  and  pathogenesis  of  which  are  entirely 
unknown.  The  question  arises  what  place  should  be  assigned  to 
these  eruptions.  The  plan  which  I  have  adopted  enables  me  to 
omit  gratuitous  hypotheses  and  avoid  forced  analogies.  These 
eruptions,  the  causes  of  which  are  multiple,  complex  or  unknown, 
;ire  not  diseases  but  pure  syndromes.  Their  morphology  is  practi- 
cally all  that  is  known  about  them.  They  have  been  described  in 
the  first  part  and  do  not  require  to  be  mentioned  in  the  second. 

THERAPEUTIC   NOTES. 

Although  I  have  carefully  indicated  the  attitude  to  be  maintained 
by  the  practitioner  in  connection  with  each  dermatosis,  1  have 
deemed  it  advisable  to  add  a  brief  therapeutic  review  to  this  book. 


INTRODUCTION  21 

It  contains  the  essential  data  required  for  dermatological  treatment 
and  the  not  very  numerous  prescriptions  which  it  is  indispensable 
to  know.  It  frequently  happens  that  these  prescriptions  are 
applicable  to  several  classes  of  cutaneous  affections;  by  uniting 
them  at  the  end  of  the  volume,  I  have  avoided  frequent  repetitions. 

Imperfect  as  it  is,  this  little  book  is  the  fruit  of  long  experience. 
I  have  practised  and  taught  dermatology  for  more  than  thirty 
years.  The  plan  was  conceived  and  the  text  frequently  revised  in 
the  hospital.  By  this  statement  I  do  not  mean  to  claim  that  all 
its  contents  are  entirely  original.  In  the  expression  of  an  opinion 
or  in  the  rendering  of  a  description,  it  is  impossible,  at  least  for  me, 
to  separate  what  is  personal  from  what  I  have  learned  from  teachers, 
from  the  literature  and  from  associates. 

A  book  of  this  kind  does  not  aim  at  replacing  the  classical  treatises, 
but  it  is  meant  to  serve  as  an  introduction  to  and  a  summary  of  these 
larger  works. 

J.  Darier. 


PART  I. 
MORPHOLOGY  OF  THE  DERMATOSES. 


CHAPTER   I. 
ERYTHEMA  AND  THE  ERYTHEMATA. 

Erythema  is  a  congestive  redness  of  the  skin,  circumscribed  or 
more  or  less  diffuse,  usually  temporary,  which  disappears  momen- 
tarily under  pressure  of  the  finger.  Redness  of  the  skin  which  does 
not  comply  with  this  definition,  such  as  the  following,  is  not  desig- 
nated as  erythema: 

Red  spots  resulting  from  the  deposit  of  a  coloring  matter  and  dis- 
appearing on  ablution.  Peristent  red  spots  of  congenital  origin, 
due  to  increase  in  size  and  number  of  the  bloodvessels,  but  not  to 
congestion;  these  are  vascular  nevi  (p.  693). 

Red  spots  which  do  not  disappear  under  pressure  of  the  finger; 
these  are  cutaneous  hemorrhages  (III). 

Erythemas  which  are  at  the  same  time  very  extensive  or  general- 
ized and  very  persistent,  are  commonly  designated  by  the  name  of 
erythroderma  (VI). 

The  term  macules  is  reserved  for  erythematous  and  pigmentary 
but  not  cicatricial  spots  following  on  cutaneous  lesions  or  eruptions 
of  any  kind  (p.  322). 

Erythema  is  the  first  and  most  common  skin  reaction  produced 
by  an  external  or  internal  irritant. 

All  acute  eruptions  and  the  great  majority  of  chronic  skin  lesions 
are  accompanied  by  reddening;  this  associated  erythema  is  such  an 
ordinary  phenomenon  that  it  only  exceptionally  requires  to  be 
taken  into  consideration. 

Simple,  more  or  less  irregular  erythema  constitutes  the  eruptive 
feature  of  a  large  complex  group  of  dermatoses  known  as  the 
Erythemata.  The  majority  of  these  affections  are  so  imperfectly 
characterized,  however,  that  it  is  usually  not  an  easy  matter  to 
determine  whether  a  given  erythema  is  a  symptom  or  a  disease, 


24  ERYTHEMA   AND   THE  ERYTHEMATA 

making  it  impossible  t<>  describe  these  conditions  separately.  The 
following,  therefore,  applies  indiscriminately  to  erythema  and  to 
the  Erythemata. 

Varieties.— I  >e] lending  on  the  apparent  pathogenesis  of  the  cuta- 
neous congestion,  it  is  customary  to  distinguish  between  active  or 
arterial  erythema,  due  to  an  increased  blood  supply,  and  passive  or 
venous  erythema,  due  to  stasis. 

Ad  I  re  erythema,  resulting  from  a  congestive  or  acute  inflammatory 
hyperemia,  is  characterized  by  a  bright  pink  color  and  a  rise  of  local 
temperature.  It  is  often  accompanied  by  a  sensation  of  heat  or  by 
itching.    As  a  rule,  it  is  ephemeral,  lasting  only  a  very  few  days. 

Passive  erythema,  on  the  contrary,  produced  by  stagnation  of  the 
blood  in  the  small  cutaneous  veins  and  capillaries,  is  of  a  darker  or 
purplish-red  color,  the  local  temperature  is  diminished;  it  sometimes 
gives  rise  to  a  sensation  of  stiffness,  with  or  without  itching,  and  is 
generally  more  or  less  persistent. 

In  a  large  number  of  cases,  it  is  impossible  to  decide  if  an  eryth- 
ema is  active  or  passive.  On  the  other  hand,  it  is  much  easier  to 
distinguish  varieties,  on  the  basis  of  whether  the  erythema  is 
deformed;  or  from  the  configuration  and  duration  of  the  eruption. 

An  erythema  is  described  as  simple  when  the  erythematous  con- 
gestion is  pure,  that  is,  when  the  change  of  color  of  the  skin  is  not 
complicated  by  any  changes  of  its  thickness,  consistence  and  epi- 
dermic surface.  Otherwise,  the  erythema  is  deformed.  As  a  matter 
of  fact,  it  frequently  happens  that  the  exaggerated  hyperemia  leads 
to  secondary  accessory  lesions,  which  more  or  less  modify  the  char- 
acters of  the  eruption;  these  must  be  interpreted  as  irregularities 
of  the  eruptive  type. 

Erythematous  congestion  may  thus  become  associated  with: 
intradermic  edema  (urticarial  erythema);  cellular  infiltration, 
manifested  by  a  hard  superficial  elevation  {papular  erythema)  or 
by  deep-seated  nodules  (nodular  erythema)',  interstitial  hemorrhage 
{purpuric  erythema);  early  or  delayed  pigmentation  (pigmented 
erythema ) ;  raising  of  the  epidermis  in  vesicles  or  bullae  (vesicular  and 
bullous  erythema);  finally  furfuraceous  or  lamellar  desquamation 
(squamous  or  desquamative  erythema). 

These  irregularities  may  be  sufficiently  marked  to  constitute 
intermediary  or  true  transition  forms,  connecting  the  erythema 
with  urticaria  (II),  papules  (VII),  nodosities  (XIV),  purpura  (III), 
the  dyschromias  (  XVI ),  bullous  dermatoses  (X),  and  erythrodermas 
(VI).  Sometimes,  real  diagnostic  as  well  as  nosographic  difficulties 
arise. 

When  in  doubt  as  to  the  classification  of  an  eruption,  either 
among  the  erythemata  or  among  the  dermatoses  of  another  group, 
it  is  advisable  to  base  one's  judgment  not  exclusively  on  the  objective 


THE  ERYTHEMATA  25 

examination  of  a  given  eruptive  feature,  but  on  the  eruption  as  a 
whole,  its  development  and  the  nature  of  the  underlying  process. 
This  rule,  although  excellent  in  certain  cases,  does  not  suffice  in 
others;  the  following  examples  are  illustrative. 

In  the  affection  described  by  Bazin  under  the  name  erythema 
induratum  of  young  girls,  histology  has  shown  the  tissue-induration 
to  be  due  to  a  tuberculoid  infiltration.  The  nature  of  the  patho- 
logical process  here  proves  the  condition  to  be  not  an  erythema, 
but  a  hypodermic  nodosity  belonging  to  the  tuberculides.  The 
erythematous  bullous  eruption  known  as  hydroa  sometimes  appears 
as  an  irregularity  or  a  variety  of  polymorphous  erythema,  or  again 
seems  to  be  closely  related  to  certain  forms  of  bullous  dermatosis. 
It  is  therefore  differently  classified  by  different  authors. 

The  configuration  and  extent  of  the  erythema  permit  a  distinction 
between  the  following  types: 

Scarlatiniform  or  Scarlatinoid  Erythema. — This  is  characterized 
by  a  more  or  less  general,  bright  and  uniform  redness.  The  red  color 
may  result  from  confluence  of  miliary  or  lenticular  hyperemic 
spots,  or  it  may  be  diffuse  from  the  start.  The  eruption  is  ephemeral 
or  more  or  less  prolonged;  it  is  often  of  medicinal  origin  (mercury, 
quinin,  opium,  etc.),  or  due  to  infection  (rash  preceding  smallpox 
or  occurring  in  the  course  of  gonorrhea,  diphtheria,  puerperal  [and 
other  streptococcic]  fevers,  indefinite  infections) .  There  exists  a  rela- 
tively durable  form,  with  general  symptoms,  recurrent  desquamative 
scarlatiniform  erythema,  which  connects  this  type  of  erythema  with 
the  primary  erythrodermias. 

Rubeoliform  Erythema. — This  is  made  up  of  small,  occasionally 
confluent  spots,  with  ragged  or  diffuse  margins,  rarely  slightly 
elevated;  desquamation  is  absent  or  insignificant.  The  eruption  is 
discrete,  regional  or  generalized  and  of  variable  duration.  The  term 
roseola  is  employed  for  nummular  or  lenticular  spots.  Four  groups  of 
roseola  are  differentiated: 

(1)  Roseolar  exanthematic fevers  (rubella,  rubeola,  seasonal  roseola) ; 
(2)  Symptomatic  infectious  roseola  (syphilitic  roseola,  typhoid  roseola 
or  lenticular  rose-spots,  roseola  of  typhus,  rash  preceding  small- 
pox, eruptions  of  cholera,  cerebrospinal  meningitis,  certain  septi- 
cemias) ;  (3)  Medicinal  roseolas  (Copaiva  balsam,  santol  oil,  turpen- 
tine, among  the  so-called  balsam  roseolas;  the  roseolas  of  quinin, 
antipyrin,  odine,  etc.);  (4)  Emotional  roseola,  which  is  not  a  true 
skin  affection,  but  a  physiological  phenomenon.  It  consists  of  a 
transitory  redness,  arranged  in  spots  or  as  a  network,  appearing 
over  the  chest,  neck  and  shoulders  of  certain  individuals  on  exposure 
of  the  person  and  identical  with  the  emotional  redness  of  the  face. 

Erythema  in  Patches  and  Figured  Erythema. — These  consist  of 
congestive  spots,  patches  or  surfaces  of  irregular  shape,  discoidal  or 


2G  ERYTHEMA    AND   THE  ERYTI1EMATA 

of  variable  configuration  (erythema  marginatum  or  annulare,  etc.). 
Although  sometimes  infectious,  this  type  of  erythema  is  more 
frequently  of  medicinal,  serotherapeutic  or  autotoxic  origin. 

The  duration  of  an  erythema,  especially  the  active  variety,  is  very 
short;  as  a  rule,  from  one  to  four  days  at  most.  Some  last  much 
longer,  however,  for  example  syphilitic  roseola.  In  certain  forms, 
there  is  a  marked  tendency  to  recurrences. 

Congestive  spots  persisting  for  several  months  are  sometimes 
designated  as  erythema  perstans,  but  do  not  represent  a  definite 
pathological  type.  The  presence  of  a  manifestation  of  this  kind 
should  suggest  conditions  such  as  tertiary  syphilitic  erythema, 
lupus  erythematodes,  parapsoriasis,  tuberculides,  the  spots  of 
macular  leprosy,  premycotic  erythema,  and  so  forth.  Under  the 
name  of  centrifugal  annular  erythema,  1  have  recently  described  an 
eruption  which  develops  acutely,  but  nevertheless  persists  for  many 
month-  on  account  of  the  constant  renewal  of  fresh  lesions.  The 
primary  urticarial  spots  become  rapidly  transformed  into  rings, 
prominent  and  solid  to  the  touch  like  cords;  their  peripheral  exten- 
sion, which  may  amount  to  several  millimeters  daily  and  the  frag- 
mentation of  the  rings,  give  rise  to  arches  or  strands  whose  design 
remains  lightly  pigmented.  This  form  of  erythema  is  peculiar  and 
very  rare;  in  the  reported  cases,  it  was  situated  on  the  buttocks, 
the  back,  and  the  thighs. 

Pathological  Anatomy. — The  clinical  appearance  of  erythema,  its 
configuration  and  the  irregularities  to  which  the  eruptive  element 
is  subject,  are  explained  to  a  certain  extent  by  the  pathological 
anatomy.  The  only  essential  lesion  is  the  dilatation  of  the  blood- 
i  ssels  of  the  cutis,  more  particularly  those  of  the  papillary  body. 
It  disappears  in  the  cadaver  and  is  usually  no  longer  recognizable 
in  cross-sections  of  microscopical  specimens. 

The  common  rounded  or  oval  configuration  of  the  spots  of  active 
erythema  is  accounted  for  by  the  anatomical  arrangement,  this 
form  being  precisely  that  of  the  vascular  territories  of  the  skin 
supplied  by  the  same  afferent  arteriole.  Between  these  territories 
of  direct  supply,  there  exists  an  anastomotic  plexus  where  the 
circulation  of  the  blood  is  normally  less  active  and  where  the  blood 
has  ;i  tendency  to  accumulate  in  erythema  due  to  stasis  (livedo 
annularis). 

Intense  congestion  may  give  rise  to  exudation  of  blood  plasma 
from  the  vessels  (urticarial  erythema)  and  to  diapedesis  of  white 
corpuscles  mixed  with  a  few  red  blood  cells.  These  elements  are 
deposited  as  cuffs  around  the  vascular  branches,  the  inflammatory 
increase  of  the  fixed  cells  contributing  to  the  production  of  indura- 
tion and  elevation  (papular  erythema  I. 

The  anatomical  explanation  of  the  pigmentation,  phlyctenization 


THE  ERYTHEMATA  27 

and  desquamation,  which  are  the  possible  results  of  erythema,  will 
be  found  elsewhere. 

Etiology. — The  causes  capable  of  producing  erythema  are 
extremely  numerous  and  varied.  An  attempt  has  been  made, 
rationally  enough,  to  group  erythema  on  the  basis  of  its  etiology, 
but  this  leads  merely  to  an  incomplete  and  artificial  classification, 
the  condition  representing  as  it  does,  not  a  disease,  but  purely  a 
symptom.  One  identical  cause  may  give  rise  to  erythema  of  a 
variable  objective  appearance  and  course;  on  the  other  hand,  the 
same  form  of  eruption  may  depend  on  several  different  causes 
acting  separately  or  together.  In  a  number  of  cases,  a  factor  of 
primary  importance,  known  as  predisposition  is  involved. 

The  actual  or  immediate  causes  of  erythema  are  either  external 
or  internal. 

External  Causes. — Erythema  from  direct  provocation;  any  slight 
traumatism  causing  local  hyperemia.  The  passage  of  the  nail  over 
the  skin  causes  the  transitory  appearance  of  a  red  line ;  an  exagger- 
ation of  this  phenomenon  acquires  a  positive  diagnostic  value  in 
certain  cases  {vasomotor  or  meningitic  streak).  Intertrigo-erythema 
is  in  part  of  mechanical  origin.  The  effects  of  repeated  friction  will 
be  pointed  out  under  the  heading  of  the  artificial  dermatitides 
(XXIII).  Caloric  and  medicinal  external  erythema  is  discussed 
in  the  same  chapter.  Erythema  a  frigore  and  active  erythema  will 
be  referred  to  presently. 

Bites  or  stings  of  the  epizoa,  lice,  bugs,  etc.,  of  various  insects, 
such  as  bees,  wasps,  hornets,  mosquitoes  and  contact  with  the 
hairs  of  certain  caterpillars  or  some  plants,  also  give  rise  either  to 
erythema  or  urticaria,  of  variable  severity  and  extent  in  different 
individuals,  or  to  a  true  inflammatory  dermatitis. 

Internal  Causes. — Erythema  may  make  its  appearance  following 
the  ingestion  of  certain  foods  or  medicinal  agents:  the  pathogenetic 
erythema  of  Bazin;  or  in  the  course  of  various  infections,  specific  or 
ordinary:  infectious  erythema;  or  finally,  under  the  influence  of  indi- 
vidual conditions  of  a  nervous,  autotoxic,  dyscratic  or  unknown  kind, 
constituting  a  predisposition  or  idiosyncrasy. 

Erythema  of  alimentary  origin  may  be  transitory  and  diffuse, 
occupying  especially  the  face  and  the  upper  part  of  the  trunk,  or 
it  may  be  more  lasting.  It  assumes  an  urticarial  or  papular  form, 
or  that  of  a  roseola  or  of  marginate  patches.  All  those  food  sub- 
stances which  are  usually  prohibited  in  urticaria  and  eczema,  have 
been  held  responsible;  although  some  of  these  really  possess  a  certain 
degree  of  toxicity,  the  majority  act  undoubtedly  only  with  the  assist- 
ance of  indigestion,  habitual  dyspepsia,  or  rather  that  of  a  predis-. 
position  which  is  now  apt  to  be  referred  to  anaphylaxis  (pp.  460,  477) . 

Medicinal  and  serotherapeutic  erythema  belong  under  the  heading 
of  the  toxidermas  (XXIII). 


28  ERYTHEMA  AND  THE  ERYTHEMATA 

Autotoxic  erythema  is  the  designation  of  conditions  developing 
in  uremia,  gout,  diabetes  and  hepatic  diseases  or  in  the  course  of 
acute  or  chronic  appendicitis,  obstinate  constipation,  etc.  Such 
cases  are  referred  to  the  production  of  autogenous  poisons  and  in- 
sufficiency of  the  renal,  hepatic,  intestinal  emunctories,  etc.  A 
popular  belief  to  the  effect  that  the  skin  under  these  conditions  is 
damaged  on  account  of  the  vicarious  role  it  is  made  to  play  in  sub- 
stitutiog  the  organs  intended  for  the  normal  purification  of  the 
organism,  is  shared  by  a  number  of  physicians,  on  what  grounds  I 
do  not  know.  This  idea  is  purely  theoretical  and  rests  on  no  reliable 
basis. 

Infectious  erythema  is  observed  in  a  large  number  of  diseases,  being 
due  either  to  the  specific  microbe  or  to  a  secondary  microbic  associa- 
tion. As  a  rule,  it  is  toxic  infectious,  the  parasite  acting  apparently 
through  the  intermediation  of  its  toxins  or  the  resulting  changes  in 
the  composition  of  the  blood.  Aside  from  the  infections  mentioned 
above,  when  speaking  of  roseola,  mention  must  be  made  of  the  follow- 
ing, as  capable  of  giving  rise  to  erythema:  Puerperal  infection,  ulcer- 
ative endocarditis,  pneumonia,  diphtheria,  the  anginas,  vaccinia, 
gonorrhea,  furunculosis,  the  pyodermatitides  in  general,  etc. 

The  possibility  that  a  nervous  influence  by  itself  alone  may  give 
rise  to  erythema  is  demonstrated  by  emotional  erythema,  usually 
very  transitory,  produced  by  emotions  such  as  shame,  anger,  joy, 
etc.,  on  the  face,  the  ears,  the  neck  and  sometimes  the  upper  part 
of  the  chest  (erythema  a  pudore).  Abnormal  psychic  or  nervous 
conditions,  such  as  are  met  with  at  the  time  of  the  menopause,  in 
exophthalmic  goitre,  etc.,  exaggerate  this  tendency  to  blushing, 
which  in  some  patients  is  almost  a  real  infirmity. 

The  existence  of  reflex  erythema  of  gastro-intestinal,  urethral, 
uterine  origin,  etc.,  has  also  been  admitted  and  it  is  naturally  diffi- 
cult in  such  cases  to  distinguish  between  the  role  of  the  intoxication 
;iml  t  lie  infection. 

Pathogenesis.-  The  pathogenetic  mechanism  is  certainly  not 
uniform  in  the  group  of  erythema.  Physiology  teaches  that  hyper- 
emia is  subject  to  vasoconstrictor  and  vasodilator  mechanisms 
located  in  the  bulbo-medullary  center  and  at  the  periphery.  These 
may  become  Involved  in  a  very  variable  manner;  by  a  local  poison,  in 
the  case  of  a  flea-bite;  by  a  psychic  disturbance  in  emotional  eryth- 
ema. 1  difficulties  arise  in  such  common  cases  as  when  an  individual 
is  attacked  by  erythema,  for  instance,  after  eating  mussels;  the  ques- 
tion is  whether  to  interpret  the  erythema  as  directly  toxic,  auto- 
toxic through  indigestion  or  of  reflex  nervous  origin.  Physicians 
used  to  hesitate  between  these  theories  and  with  good  reason,  for 
they  are  probably  all  wrong.  In  a  patient  in  my  service,  who 
was  attacked  by  urticaria  under  these  conditions,  the  existence  of 


THE  ERYTHEMATA  29 

anaphylaxis  was  demonstrated  by  Ch.  Flandin  and  Tzanck.  At 
any  rate,  it  is  well  to  keep  in  mind  that  a  series  of  experimental 
investigations,  in  harmony  with  the  findings  of  pathological  histology 
seem  to  prove  that  in  the  great  majority  of  erythemas,  those  at  least 
which  are  not  absolutely  transitory,  the  process  involved  is  a  local 
inflammation  and  not  simply  an  angioneurosis,  as  had  been  assumed. 

In  some  instances  of  infectious  erythema,  the  actual  presence  of 
microbes  has  been  recognized  in  the  skin.  This  is  the  case  in  the 
rose  spots  of  typhoid  fever,  some  forms  of  gonorrheal  and  pyococcal 
erythema  and  syphilitic  roseola.  When  no  microbes  are  found,  it 
may  be  assumed  that  they  have  already  disappeared.  But  it  is 
extremely  probable  that  in  numerous  cases  the  microorganisms 
act  merely  indirectly. 

Recently  acquired  knowledge  of  serotherapeidic  erythema  sheds 
some  light  on  the  pathogenesis  of  erythema  in  general.  I  shall  have 
occasion,  further  on,  to  point  out  that  the  complication  of  serum- 
treatment  must  be  interpreted  as  manifestations  of  anaphylaxis.  It 
is  probably  not  the  anaphylactic  poison  itself,  the  apotoxine  of  Ch. 
Richet,  which  acts  in  the  serum-eruptions.  There  is  good  reason 
to  believe  that  changes  in  the  composition  of  the  blood  are  respon- 
sible, perhaps  the  presence  of  precipitins,  as  assumed  by  Hamburger 
and  Moro,  Marfan  and  Rovere,  or  perhaps  other  antibodies  or 
derived  substances  of  local  origin,  or  disseminated  by  embolism. 

What  is  true  for  the  serum  eruptions  is  equally  applicable  perhaps 
to  toxinic  erythema  and  infectious  erythema.  We  know  that  the 
injection  of  Koch's  tuberculin  into  tuberculous  subjects  invariably 
produces  a  local  erythematous  patch,  sometimes  of  erysipeloid 
type;  in  some  cases  it  causes,  moreover,  the  appearance  of  a  general- 
ized eruption  of  more  or  less  urticarial  erythema.  It  is  probable  that 
in  the  last  named  cases  the  composition  of  the  blood  is  different. 

In  children  suffering  from  severe  diphtheria  and  treated  with 
serum,  there  occurs  not  only  an  attack  of  urticaria  or  marginate 
erythema,  but  scarlatiniform  and  morbilliform  erythema  is  likewise 
observed  and  the  question  arises  if  these  eruptions  are  referable  to 
the  serum  or  are  of  infectious  origin. 

The  subject  is  complicated  and  not  yet  settled.  What  seems  to 
be  established  is  that  in  the  pathogenesis  of  many  forms  of  erythema, 
just  as  is  true  for  certain  urticarias,  purpuras,  etc.,  there  is  reason 
to  admit  the  intermediation,  between  the  pathogenic  agent  (foreign 
serum,  microbe,  toxine)  and  the  eruption,  of  some  change  in  the 
humoral  composition  of  the  blood. 

The  ancient  formulas  in  regard  to  the  pathogenic  factors  of  eryth- 
ema are  thus  peculiarly  vindicated.    I  was  right  in  asserting  that . 
"while  certain  agents  more  or  less  readily  produce  eruptions  in  all 
persons,  others  necessarily  require  a  predisposition  and  active  co- 


30  ERYTHEMA   AXD   THE   ERYTHEMATA 

operation  of  the  organism/'  E.  Besnier  correctly  taught  that  "the 
apparent  cause  of  the  eruption  sometimes  seems  to  determine  neither 
its  form  nor  its  course;"  and  that  "the  ordinary  causes  merely 
bring  out  the  morbid  tendency."  It  is  thus  understood  why  Brocq 
refused  to  group  erythema  among  the  true  morbid  entities,  but  made 
it  one  of  the  chief  types  of  his  "cutaneous  reactions."  Recent 
investigations  serve  to  confirm  these  clinical  observations. 

Prom  all  that  has  been  said  so  far,  it  results  that  the  few  dermatoses 
of  erythematous  type,  to  be  presently  described,  cannot  be  referred 
to  a  definite  etiology  and  pathogenesis.  It  would  be  a  much  too 
simple  as  well  as  an  erroneous  conception  of  the  subject  to  assume 
outright  that  intertrigo  is  an  erythema  of  mechanical  origin;  that 
■sun hum,  frost-bite,  and  livedo  are  dependent  on  a  physical  cause; 
that  rosacea  results  from  an  auto-intoxication;  or  that  erythema 
multiforme  is  infectious.  These  are  not  morbid  entities,  but  simple 
syndromes. 

Syphilitic  roseola  is  the  only  example  I  shall  quote  of  an  erythema 
having  a  definite  cause,  the  eruptive  manifestation  of  an  actual 
disease. 

INTERTRIGO. 

The  congestive  redness  which  seems  to  result  from  mutual  friction 
of  two  contiguous  surfaces,  is  designated  as  intertrigo.  This  term 
should  preferably  be  employed  only  as  an  adjective,  attaching  it 
to  the  name  of  the  dermatosis  produced  by  these  conditions.  As  a 
matter  of  fact,  aside  from  intertrigo-erythema,  there  exists  intertrigo- 
eczema,  etc. 

Intertrigo-erythema  is  ordinarily  observed  especially  in  obese 
individuals,  in  the  fold  between  the  buttocks  and  on  the  internal 
surface  of  the  thighs,  for  example  after  a  lengthy  march.  In  stout 
women,  it  is  also  seen  under  the  breasts,  in  the  hypogastric  fold, 
in  the  groin  and  axillary  regions,  or  in  newborn  infants,  on  the 
buttocks,  the  folds  of  the  neck,  etc. 

Tlie  more  or  less  vivid  redness  is  bounded  by  irregular  or  diffuse 
margins;  there  is  local  heat  or  pruritus;  pigmentation  and  sometimes 
licheni/.ation  finally  develop.  To  the  mechanical  causes  arc  added 
the  harmful  effects  of  sweating,  maceration,  regional  secretions, 
secondary  fermentations  and  infections;  so  that  the  erythema  is 
frequently  complicated  by  dermatitis,  lymphangitis,  pyodermatitis, 
eczematous  changes,  etc.,  which  may  spread. 

The  inguinal  intertrigo  of  adults  is  distinguished  from  erythrasma 
(p.  532)  and  from  the  eczema  marginatum  of  Hebra  (p.  524)  by  its 
always  symmetrically  affecting  the  two  sides  of  the  fold,  which  is 
often  fissured;  and  especially  by  the  lesions  of  intertrigo  being 


INTERTRIGO 


31 


neither  uniform,  nor  polycyclic,  nor  marginate,  having  on  the  con- 
trary more  or  less  diffuse  borders. 

Infantile  gluteal  erythema  is  related  to  intertrigo  and  radiates 
from  the  intergluteal  fold  to  the  thighs,  the  back,  the  abdomen, 
even  as  far  as  the  heels.  It  is  extremely  common  and  due  not  so 
much  to  friction  as  to  contact  of  the  skin  with  the  dejecta,  especially 
in  the  presence  of  diarrhea  or  athrepsia.  Sometimes,  the  condition 
is  a  simple  hyperemia,  often  of  a  coppery  red  color,  covering  a  large 
area,  or  in  patches;  in  other  cases,  the  erythema  is  complicated  by 
fissures  or  vesicles  and  oozing  erosions,  briefly  by  true  eczematous 
changes  (intertrigo  eczema  of  the  newborn)  as  shown  by  Marcel 
Ferrand;  or  again,  it  becomes  covered  by  ulcerations  and  pyodermal 
lesions. 


Fig.  1. — Syphiloid  (non-syphilitic)  dermatitis  of  the  buttocks  in  the  newborn. 


In  a  form  described  under  the  name  of  'payulo-lenticular  erythema 
or  yosterosive  syphiloid  by  Sivestre  and  Jacquet,  the  erosions  appear 
as  raised,  moist  papules. 

Several  varieties  of  these  eruptions  very  closely  simulate  the 
polymorphous  syphilides  of  the  newborn,  as  may  be  seen  from  the 
illustration  (Fig.  1)  and  the  description  of  the  latter.  The  diagnosis, 
in  doubtful  cases,  rests  on  the  general  examination  of  the  child  and 
its  environment,  the  direct  discovery  of  the  spirochete  in  the  lesions, 
the  Wassermann  reaction  of  the  little  patient  and  its  mother  and 
finally  on  the  course.  As  long  as  any  doubt  remains  all  precautionary 
measures  must  be  taken  to  guard  against  contagion. 

The  treatment  of  intertrigo  consists  in  the  frequent  application 
of  astringent  or  weakly  antiseptic  soothing  lotions.  An  essential 
precaution  is  the  successful  separation  of  the  affected  surfaces,  by 


32  ERYTHEMA  AND  THE  ERYTHEMATA 

means  of  sterilized  gauze,  or  especially  by  neutral  mineral  powders. 
Zinc  oxide  pastes  are  also  appropriate,  but  salves  are  often  injurious. 
The  diet  of  children  must  be  closely  watched,  and,  if  necessary, 
corrected. 

ERYTHEMA  SOLARE  SEU  ACTINICUM. 

The  inflammatory  redness  which  follows  after  exposure  to  the 
rays  of  the  snn  is  known  as  .sunburn.  At  the  end  of  a  few  hours, 
the  exposed  surfaces,  usually  the  face,  especially  the  nose  and  ears 
and  the  hands,  present  an  intense  congestion,  with  swelling,  burning 
and  itching;  this  lasts  a  few  days,  then  the  epidermis  desquamates 
in  Large  shreds  and  only  a  slight  pigmentation  is  left  behind.  Not 
all  individuals  exposed  to  light  radiations  are  affected  to  the  same 
degree.  Delicate  skins,  blondes,  certain  neuropaths  and  persons 
not  accustomed  to  the  open  air,  are  more  susceptible  to  sunburn, 
especially  in  the  spring  near  the  water,  or  in  excursions  on  glaciers. 

Insulation,  or  heat-stroke,  is  an  altogether  different  accident, 
sometimes  very  grave,  characterized  by  general  phenomena  instead 
of  cutaneous  lesions  and  referable  to  a  different  pathogenesis. 

Solar  erythema  differs  also  from  burns.  It  has  been  more  than 
sufficiently  demonstrated  that  it  is  not  the  caloric  rays,  but  the 
chemical  rays  of  the  spectrum,  the  violet  and  ultraviolet  rays  which 
are  responsible  in  these  cases.  The  electric  arc-light  is  accordingly 
capable  of  producing  an  entirely  similar  electric  erythema.  The  same 
chemical  radiations  are  utilized  in  phototherapy,  for  example  in 
Finsen's  method. 

A  few  very  simple  precautions,  such  as  wearing  a  veil,  the  appli- 
cation of  creams,  lotions,  or  powders  made  with  quinin  or  esculine, 
suffice  to  protect  against  sunburn.  The  treatment  is  that  of  an 
artificial  dermatitis  or  a  burn  of  the  first  degree.  Numerous 
observers  believe,  not  without  good  reason,  that  the  action  of  the 
solar  rays  plays  a  part  in  the  production  of  pellagrous  erythema. 

Pellagra  is  a  non-contagious  general  disease,  endemic  in  many 
countries,  notably  in  Italy  (mal  della  rosa),  where  for  a  long  time 
it  has  constituted  a  veritable  scourge;  in  the  Balkan  provinces,  in 
Spain,  in  southwestern  France,  in  Egypt  and  in  Asia  minor.  In  the 
last  ten  years,  important  foci  have  been  discovered  in  the  United 
States,  Guyana,  the  Antilles,  and  a  few  cases  in  Great  Britain. 

Pellagra  usually  starts  in  the  spring,  followed  by  seasonal  out- 
breaks. The  erythema  which  often  betrays  its  presence,  manifests 
itself  on  the  exposed  parts,  especially  on  the  back  of  the  hands  and 
the  wrists,  sometimes  on  the  face,  neck,  upper  part  of  the  trunk,  and 
even  on  the  dorsal  aspect  of  the  feet.  It  consists  of  a  sombre  redden- 
ing, with  more  or  less  clearly  marked  outlines,  sometimes  com- 
plicated by  small  bloody  suffusions,  fissures,  or  bullae.    [The  sharp 


ERYTHEMA  SOL  ARE  SEU  ACTINICUM 


:;:; 


line  of  demarkation  between  the  affected  areas  and  the  normal  skin 
is  very  characteristic  of  pellagrous  erythema.]  At  the  end  of  two 
or  three  weeks  the  skin  becomes  pigmented,  darkens,  and  is  shed  in 
large  shreds,  finally  undergoing  atrophy,  so  as  to  resemble  the  skin 
in  certain  senile  cachexias.  Lesions  of  the  mucous  membranes  are 
not  infrequently  observed,  for  example  a  bullous  and  later  on 
diphtheroid  stomatitis,  as  well  as  an  analogous  vulvitis. 

Aside  from  the  cutaneous  symptoms,  a  very  marked  loss  of 
strength  is  noted  after  the  onset  of  the  disease,  followed  by  a  true 
asthenia,  with  serious  digestive  disturbances,  anorexia,  fetid  diar- 
rhea, emaciation,   sometimes  chills  and  fever,   ordinarily  serious 


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Fig.  2.— Pellagra.     Si 


r,  Garrison  and  MacNeal,  Thompson-McFadden  Pellagra 
Commission. 


mental  and  nervous  disturbances,  paresthesias,  hyperesthesias, 
convulsions,  melancholia  and  delirium  with  a  tendency  to  suicide. 
Many  patients  drift  into  insane  asylums.  The  mortality  in  certam 
foci  is  appalling,  but  there  are  numerous  abortive  cases  which  may 
remain  unrecognized. 

The  theory  according  to  which  pellagra  is  due  to  a  chronic  intoxi- 
cation by  spoiled  maize  (Zeism)  has  been  widely  accepted.  It  is 
claimed,  however,  that  pellagra  appears  also  in  regions  where  maize 
(Indian  corn)  is  never  used.  The  infectious  theory,  which  is  now 
opposed  to  the  maize  theory,  acquires  much  probability  from  recent 
epidemiological  investigations,  notably  those  of  L.  W.  Sambon: 
Simulides  or  other  insects  are  assumed  to  act  as  carriers  of  a  special 
3 


34  ERYTHEMA   AND  THE  ERYTHEMATA 

protozoan  parasite,  supposed  to  be  the  causative  agent  of  pellagra. 
There  would  thus  be  a  remarkable  parallelism  between  this  disease 
and  malaria.  [The  etiology  of  pellagra  is  not  clear  but  the  weight  of 
evidence  at  present  would  indicate  that  the  disease  is  one  of  mal- 
nutrition due  to  a  defective  diet.  The  parallelism  is  rather  with  beri- 
beri than  malaria.  1  1  >oubt  prevails  as  to  the  nature  of  an  absolutely 
identical  or  sometimes  attenuated  syndrome  which  may  be  observed 
in  European  countries  among  cachectic  individuals,  inebriates, 
or  in  those  in  a  state  of  physical  and  moral  deterioration.  Some 
interpret  this  syndrome  as  a  pellagroid  erythema  of  alimentary  or 
cachectic  origin,  whereas  others  admit  no  essential  difference  between 
this  pellagroid  and  true  pellagra.  The  point  has  not  yet  been  settled. 

ERYTHEMA  PERNIO  OR  FROST-BITE. 

Everybody  knows  frost-bite,  in  the  form  of  a  purplish  and  painful 
reddening  frequently  observed  during  the  cold  season,  especially 

in  children  and  youthful  individuals.  In  order  of  frequency,  these 
lesions  affect  the  hands,  notably  the  ulnar  border  and  the  fingers,  the 
toes  and  heels,  the  ears,  the  nose  and  more  rarely  the  cheeks. 

In  thejirsf  degree  they  consist  of  a  swelling  of  the  skin,  which  is  of 
a  dark  or  bluish-red  color,  tense,  glazed,  indurated  and  cold  to  the 
touch.  Although  the  erythema  is  evidently  due  to  stagnation, 
there  occurs  an  instantaneous  active  hyperemia  when  the  parts  are 
too  rapidly  heated,  the  sensation  of  stiffness  changing  into  an  itching 
and  very  painful  burning  sensation. 

The  erythema  may  be  limited  to  patches,  or  diffusely  outlined  or 
even  generalized  over  nearly  the  entire  region. 

In  the  second  degree,  the  frost-bite  is  "open,"  as  it  is  ordinarily 
described.  The  ulcerations  result  either  from  cracks  which  appear 
in  the  folds,  or  from  sometimes  rather  large  bullae  which  originate 
on  the  swollen  surfaces,  probably  under  the  influence  of  infection  by 
pus-cocci.  A  persistent  exudation  follows,  or  a  suppuration  with 
crusts,  which  may  lead  to  spongy  bleeding  ulcers,  causing  an  actual 
lo>>  of  substance.  Under  these  conditions,  manual  labor  or  walking 
sometimes  become  impossible. 

Untreated  frost-bites  usually  last  with  exacerbations  through  the 
entile  winter  and  disappear  in  the  spring;  but  there  are  exceptional 
cases  which  persist  even  in  the  summer. 

The  part  played  by  the  season  and  the  local  action  of  the  cold  are 
beyond  dispute.  However,  the  determining  causes  must  not  be 
allowed  in  overshadow  the  predominating  importance  of  the  soil. 
The  age  of  five  to  fifteen  years  predisposes  to  frost-bite;  but  not  all 
children  are  attacked,  and  moreover,  cases  are  observed  in  young 
and  adult  individuals.    Anemia,  the  so-called  lymphatic  constitu- 


ERYTHEMA  PERNIO  OR  FROST-BITE  35 

tion  and  arterial  hypotension,  are  evidently  very  often  involved; 
it  may  even  be  stated  that  the  frequently  observed  association  of 
frost-bite  with  habitual  acro-asphyxia,  with  adenopathies,  with  the 
scrofulous  diathesis,  might  cause  them  to  be  classified  among  the 
manifestations  of  attenuated  tuberculosis  which  are  now  designated 
as  tuberculides  (p.  563).  This  view  is  supported  by  the  not  uncom- 
mon cases  where  the  frost-bite  is  apparently  transformed  into 
erythematous  lupus,  the  chilblain  lupus  of  Hutchinson;  indicating  a 
probable  relationship  between  these  two  affections,  the  second  of 
which  is  considered  as  a  tuberculide  (p.  571).  The  cases  in  which 
chilblains  give  rise  to  angiokeratoma,  or  alternate  with  papulo- 
neurotic  tuberculide,  point  in  the  same  direction. 

*  Treatment. — In  frost-bite  of  the  first  degree,  the  patient's  suffer- 
ings are  greatly  relieved  by  means  of  lotions  made  with  lukewarm 
or  warm  water,  followed  by  rubbing  with  camphorated  spirits, 
alcohol  with  a  little  iodin,  or  an  infusion  of  tannic  acid.  Salves  or 
powders  made  with  tar  or  ichthyol  are  sometimes  useful. 

In  case  of  cracks  or  ulcerations,  a  moist  occlusive  dressing  is 
applied,  or  applications  of  linimentum  calcis  or  vasolanoline, 
until  cicatrization  is  obtained,  before  resorting  to  astringents  and 
keratoplastic  agents,  such  as  ichthyol,  resorcinol,  etc. 

Hydrogen  peroxide  in  local  baths  of  fifteen  to  twenty  minutes, 
repeated  two  or  three  times  daily,  is  often  remarkably  successful. 

The  "biokinetic  method"  of  Jacquet,  provided  it  is  properly 
applied,  constitutes  a  preventive  and  excellent,  treatment  of  frost- 
bite and  chilblains.  The  patient  must  actively  move  (8  or  10  times 
daily  for  five  minutes)  all  the  joints  of  the  affected  extremities, 
which  meanwhile  are  kept  in  an  elevated  position. 

General  medicinal  treatment,  as  employed  in  the  lymphatic  and 
scrofulous  diathesis,  must  not  be  omitted,  in  the  form  of  fresh  air, 
dry  or  alcoholic  rubs,  cod-liver  oil,  arsenic,  calcium,  iodide  of  iron, 
etc.  Certain  forms  of  opotherapy  are  sometimes  indicated  (supra- 
renal extract,  etc.). 

The  disease  known  as  trench-foot  (said  to  be  frozen  feet),  and 
frequently  observed  in  the  great  war,  differs  from  chilblains  in  many 
respects.  It  occurs  in  soldiers  who  have  been  obliged  to  stand 
several  days  in  cold  water  or  mud,  even  in  the  absence  of  ice,  and 
is  the  result  of  the  enormous  withdrawal  of  heat,  together  with  the 
effects  of  the  [prolonged  erect  or]  slanting  position,  the  general 
fatigue  and  sometimes  the  constriction  of  the  legs  and  feet.  It 
consists  of  a  purplish  and  very  painful  swelling,  which  interferes 
with  walking,  either  without  cutaneous  lesions  or  accompanied  by 
purpura,  bullae,  or  even  more  or  less  extensive  and  deep  sloughs. 
In  such  cases  we  have  noted,  with  Civatte,  a  very  persistent,  pain- 
ful anesthesia  of  the  distal  end  of  the  foot,  indicative  of  peripheral 


36  ERYTHEMA  AND  THE  ERYTHEMATA 

neuritis.  Vascular  lesions  are  held  responsible  by  others.  The 
duration  may  be  several  months,  even  in  cases  which  receive  proper 
treatment  with  baths  or  douches  of  hot  air  and  kinetotherapy  in 
the  elevated  position. 

ACRO   ASPHYXIA  AND  LIVEDO. 

Acro-asphyxia  and  livedo  are  two  other  forms  of  passive  erythema 
which  musl  be  considered  in  connection  with  chilblains. 

Arm-asphyxia  is  a  chronic  congestion  of  the  extremities,  which 
an-  of  a  purplish  red  color,  habitually  cold  and  often  damp  and 
flaccid.  The  ischemic  spot  produced  by  digital  pressure  requires  a 
long  time,  sometimes  nearly  a  minute,  to  resume  its  red  color  by  the 
inflow  of  blood. 

This  affection  is  observed  under  a  variety  of  conditions. 
Obviously,  this  syndrome  can  be  produced  by  a  spasm  of  the  veins, 
a  change  of  the  venous  walls  or  a  lowering  of  the  arterial  tension 
(cardiac  or  pulmonary  lesions,  cachexia).  Permanent  nervous  dis- 
turbances, nutritional  impairment  and  chronic  exogenous  or  autog- 
enous  intoxications  may  undoubtedly  lead  to  the  same  result. 
Children  or  youthful  individuals  having  the  scrofulous  diathesis 
are  particularly  susceptible.  The  manifestations  are  accentuated 
by  cold. 

Without  itself  causing  seriotis  inconvenience,  acro-asphyxia 
creates  a  scat  of  predilection  for  chilblains,  tuberculides,  angio- 
keratoma, artificial  dermatitides  and  pyodermatitides  and  imposes 
;i  sluggish,  dragging  tendency  on  the  course  of  all  these  skin  lesions. 

Livedo  (livedo  annularis  a  frigore  or  reticular  asphyxia)  has  a 
practically  identical  etiology  and  significance.  It  is  observed 
especially  on  the  outer  aspect  of  the  forearms,  arms  and  thighs,  on 
the  Hanks  and  sometimes  over  almost  the  entire  integument. 

It  consists  <•!'  a  persistent  purplish  reddening,  increased  by  cold, 
which  appears  on  the  skin  as  a  network  made  up  of  strands  of 
variable  size,  enclosing  round  or  oval  meshes.  These  meshes  have  a 
normal  color  and  correspond  to  the  territories  of  direct  blood  supply, 
whereas  the  strands  of  the  network  represent  the  anastomotic 
zones  between  these  territories.  Livedo  accordingly  represents  the 
"  negative"  of  a  roseolar  eruption. 

ROSACEA. 

Rosacea  (acne  rosacea,  acne  rosea,  gntta  rosea,  Fr.  couperuse)  is 
;i  3pecial  affection  of  the  face,  a  passive  erythema,  persistent  but 
variable,  sometimes  complicated  by  pustules.  Its  principal  local- 
ization is  the  nose,  the  cheek  and  the  middle  of  the  forehead;  by 
extension,  it  may  reach  the  chin  and  the  temples. 


ROSACEA  37 

Etiology. — Rosacea  does  not  occur  in  children;  it  appears  either 
after  puberty,  or  more  generally  toward  the  age  of  forty  or  fifty 
years  in  women  at  the  time  of  the  menopause.  It  usually  disap- 
pears in  old  age. 

Many  different  factors  may  enter  into  its  etiology.  It  is  very 
frequently  preceded  by  a  stage  of  acute  congestion  of  the  face, 
recurring  in  attacks  and  designated  as  erythrosis  facialis;  on  the 
other  hand,  it  almost  invariably  enters  into  the  symptom-complex 
of  kerosis  (p.  196)  with  or  without  seborrhea.  Both  these  morbid 
conditions  act  as  intermediaries  between  the  general  disturbances 
presently  to  be  enumerated  and  the  chronic  erythema  of  the  face 
which  we  call  rosacea. 

Most  commonly,  digestive  disturbances  are  responsible,  such  as 
habitual  constipation,  gastro-intestinal  fermentations,  hepatic 
dyspepsia,  abuse  of  stimulants,  etc.  Many  people,  especially  young 
women,  are  subject  to  attacks  of  acute  congestion  of  the  face, 
diffuse  or  in  patches,  after  eating  too  rapidly  without  sufficient 
chewing  (  tachyphagia),  or  under  the  influence  of  certain  foods  or 
beverages.  This  facial  erythrosis,  which  seems  to  be  the  effect  of  a 
reflex  of  gastric  origin  (L.  Jacquet)  may  recur  during  several  years, 
or  it  may  change  rather  rapidly  into  rosacea.  In  other  cases,  rosacea 
is  established  from  the  start  with  persistent  red  spots  which  have 
a  tendency  to  become  confluent.  This  is  apt  to  be  the  case  in 
inebriates,  especially  wine-drinkers;  the  florid  complexion  and  red 
nose  are  not  a  sign  of  splendid  health,  but  rather  an  index  of 
gastro-hepatic  dyspepsia. 

Disturbances  of  the  genital  functions,  especially  utero-ovarian; 
the  menopause;  dysmenorrhea;  inflammations  of  the  tubes  and 
ovaries;  metritis,  etc.,  likewise  predispose  to  rosacea  and  especially 
to  its  localization  on  the  chin.  Chronic  cardiac  and  pulmonary 
lesions  are  occasionally  responsible.  Affections  of  the  nasal  fossae 
and  sinuses  apparently  invite  the  skin  lesion  in  a  number  of  cases 
and  the  same  is  true  for  dental  caries,  which  through  the  loss  of 
many  teeth,  moreover,  becomes  an  important  cause  of  dyspepsia. 

The  action  of  cold,  heat,  or  wind;  the  menstrual  periods;  cutaneous 
irritations  of  all  kinds,  contribute  to  the  renewal  of  attacks  and  to 
the  coalescence  of  the  red  spots,  which  become  darker,  of  a  purplish 
or  dark  blue  color,  or  to  the  exacerbation  of  rosacea  already  estab- 
lished. 

Symptoms. — In  its  fully  developed  stage,  rosacea  consists  of  a 
persistent  more  or  less  diffuse  redness,  without  elevation  of  the  local 
temperature.  After  a  while,  superficial  telangiectases  make  their 
appearance;  small  undulating  veins  ramify  over  the  nasogenial 
grooves,  furrow  the  wings  of  the  nose  and  twist  in  intertwining 
twigs  over  the  nose,  the  cheeks,  the  temples,  the  forehead,  and  the 


38  ERYTHEMA   AND  THE  ERYTHEMATA 

chin.  In  well-marked  cases  of  kerosis,  the  skin  becomes  swollen, 
thickened  as  n  whole,  and  a  few  hypertrophied  sebaceous  glands 
may  project  over  the  surface.  This  condition  in  particular  is  desig- 
nated popularly  as  "gin-blossom." 

Although  rosacea  may  run  its  course  unmixed,  it  very  frequently 
becomes  complicated  by  folliculitis,  especially  in  patients  having 
seborrhea.  The  majority  of  authors  have  on  the  other  hand  inter- 
preted this  acneiform  folliculitis  as  primary  and  causative  of  the 
surface  redness.  Careful  observation  of  these  patients  shows  this 
to  be  incorrect.  These  follicular  inflammations  have  also  been 
generally  confused  with  the  papulopustules  of  acne  vulgaris  (p.  385). 
lima  has  shown  that  they  differ  from  the  latter  by  the  absence  of 
comedones,  by  their  superficial  situation,  by  their  localization  and 
by  the  age  of  the  patients. 

The  follicular  inflammations  of  rosacea  appear  in  attacks  affecting 
from  two  to  ten  follicles  at  once;  they  pass  through  all  the  stages 
of  papules,  pustules,  crusts,  lasting  from  two  to  four  days  and  are 
constantly  repeated.  Overindulgence  in  food,  however,  may  give 
rise  to  a  crop  of  twenty  to  thirty  inflamed  follicles.  They  aggra- 
vate the  previous  condition,  unpleasantly  affecting  the  patient's 
appearance  and  inevitably  leaving  at  least  a  minute  cicatrix.  An 
extreme  degree  of  rosacea  seriously  disfigures  the  sufferer.  The 
purple  pimply  nose,  deformed  by  swollen  ridges  separated  by  deep 
grooves,  traversed  by  large  dilated  veins,  is  increased  in  size  in  all 
directions;  this  condition  has  been  described  as  a  separate  affection 
under  the  name  of  rhinophyma  (p.  374J.  The  other  parts  of  the  face 
are  sometimes  likewise  purplish,  swollen  and  scattered  over  with  pus- 
tule-, cicatrices  and  telangiectases.  The  general  impression  is  far 
from  esthetic. 

Diagnosis.  The  diagnosis  of  rosacea  is  generally  easy,  except 
perhaps  when  it  presents  certain  features  suggestive  of  iodides  and 
bromides,  or  of  lupus  pernio,  which  is  by  no  means  limited  to  the 
nose,  or  of  lupus  erythematodes,  which  is  characterized  by  the 
sharp  outline  of  its  margins.  The  differentiation  from  certain  ter- 
tiary syphilides  of  the  middle  of  the  face  may  prove  extremely 
difficult. 

Treatment.  In  the  first  place,  the  various  etiological  factors 
referred  to  above  must  be  looked  for  and  appropriate  diet  and 
internal  treatmenl  prescribed.  The  local  treatment  varies  with  the 
degree  of  i  he  affecl  ion  and  the  presence  or  absence  of  complications. 
In  ,i  moderately  >v\cw  or  mild  case,  the  rule  is  to  exhaust  the  power 
of  topical  agents  before  resorting  to  the  obliteration  of  the  dilated 
vessels.  ( Ointments  are  often  badly  tolerated.  Sulphur  and  ichthyol 
pastes,  powders,  bathing  with  lukewarm  naphthol  or  ichthyol  soap 
solution,  sprays  or  warm  lotions  with  astringent  fluids  with  or  with- 


ERYTHEMA  MULTIFORME  39 

out  the  addition  of  bichloride  are  decidedly  preferable.  A  sulphur 
and  camphor  lotion  may  by  itself  alone  lead  to  considerable  improve- 
ments provided  the  general  indications  have  been  met.  Local 
massage,  or  better  still,  frequent  sessions  of  facial  gymnastics,  advo- 
cated by  L.  Jacquet  are  often  very  efficient.  Finally,  when  required, 
the  treatment  may  proceed  to  obliteration  of  the  telangiectases, 
preferably  with  the  galvanocautery,  or  exceptionally  by  means  of 
electrolysis  or  scarifications. 

In  a  grave  case  of  rhinophyma,  after  relieving  the  irritation  and 
checking  the  suppuration  by  the  application  of  mild  antiseptic 
sprays  and  dressings,  surgical  intervention  may  prove  necessary 
in  the  form  of  nasal  decortication. 


ERYTHEMA  MULTIFORME. 

Under  the  name  of  multiform  or  polymorphous  exudative  ery- 
thema, Hebra  distinguishes  in  the  heterogeneous  group  of  erythema 
a  syndrome  which  one  is  almost  tempted  to  regard  as  a  disease. 
In  its  behavior  it  approaches  the  eruptive  fevers,  but  as  it  is 
neither  specific  nor  contagious,  it  must  be  described  as  pseudo- 
exanthematic. 

Symptoms. — The  eruption,  which  is  often  accompanied  by  sys- 
temic phenomena,  consists  either  of  erythematous  papular  elements, 
or  of  vesicles  or  bullae,  or  finally  of  nodosities.  It  is  somewhat 
uncommon  to  see  these  different  forms  of  elements  combined  in  the 
same  individual. 

The  following  types  may  therefore  be  described :  Papido-erythem- 
atous,  which  alone  will  be  discussed  here;  a  bullous  type  or  hydroa 
(p.  175)  and  the  so-called  erythema  nodosum  (p.  265).  Polymor- 
phous erythema  of  the  papulo-erythematous  type  is  characterized 
by  nummular  or  lenticular  congestive  spots,  the  center  of  which 
promptly  becomes  cyanotic;  these  spots  spread,  remaining  flat  or 
becoming  wheal-like  or  papular,  sometimes  discoid,  or  depressed  in 
their  center  (Fig.  2).  The  livid  color  of  the  spots,  their  bright-red 
border,  their  manner  of  development  and  the  distribution  of  the 
eruption  are  sufficiently  characteristic.  The  lesions  may  also  be 
whitish  in  their  middle,  appear  to  be  bullous  or  actually  become  so 
in  some  cases;  or  again,  their  center  may  become  purpuric.  Their 
extension  is  rapid  and  sometimes  gives  rise  to  marginate  spots,  or 
even  to  rings,  through  the  obliteration  of  the  central  area  (erythema 
annulare). 

The  eruption  is  composed  of  a  very  variable  number  of  elements, 
disseminated  or  arranged  in  groups,  sometimes  confluent,  usually 
symmetrical.  The  seat  of  predilection  is  the  dorsal  surface  of  the 
wrists,  hands  and  forearms;  it  sometimes  occurs  on  the  fingers,  the 


40 


ERYTHEMA   AND  THE  ERYTHEMATA 


elbows,  the  nape  of  the  neck,  the  forehead,  the  knees,  and  rarely 
the  feet.  Heat,  pruritus  and  local  tension  are  present,  often  regional 
swelling,  sometimes  arthralgias  or  even  arthritis  simulating  acute 
articular  rheumatism;  prostration,  headache,  gastric  disturbance 
and  some  fever  at  the  onset.  As  a  rule  the  eruption  extends  by 
successive  attacks.  The  entire  duration  is  from  one  to  five  weeks. 
Moderate  desquamation  is  noted  on  its  subsidence. 

Relapses  are  not  uncommon;  and  Brocq  finds  in  these  relapses  a 
connecting  link  between  the  recurrent  cases  with  grouped  lesions 
accompanied  or  not  by  especially  painful  phenomena  and  the 
painful  polymorphous  dermatitides  (p.  179). 


pular  type. 


Etiology.-  Notwithstanding  its  appearance  of  a  fairly  well 
defined  morbid  entity,  polymorphous  erythema  seems  due  to  quite 
a  number  of  ordinary  causes.  The  effects  of  cold,  alimentary  or 
medicinal  intoxications;  infections,  such  as  rheumatism,  the  anginas, 
gonorrhea,  syphilis,  tuberculosis,  leprosy  and  perhaps  reflex  actions 
or  auto-intoxications  may  all  be  present,  without  lending  a  special 
feature  to  the  disease.  In  other  words,  the  true  cause  is  not  known. 
It  is  probably  a  reaction  of  the  organism  under  the  influence  of 
various  intoxications  or  toxins.  [There  is  reason  to  believe  that 
low-grade  infections  are  the  most  frequent  etiological  factor.] 

Treatment.-  In  the  first  place  this  must  not  be  irritating.  Accord- 
ing to  the  cases,  purgatives,  rest,  a  light  diet  may  suffice;  calcium 
chloride,  aspirin  and  salicylates  are  often  useful;  iodides  have  been 


SYPHILITIC  ROSEOLA  41 

highly  recommended,  but  are  rather  injurious.  Locally,  applications 
of  neutral  powders  will  suffice,  with  protective  dressings  if  needed. 

As  it  has  been  shown  by  the  work  of  Prof.  Landouzy  and  his 
pupils  that  polymorphous  erythema  in  a  considerable  number  of 
cases  is  due  to  tuberculosis,  it  is  advisable  to  prescribe  an  appropriate 
hygiene  for  convalescent  patients  and  to  keep  them  under  prolonged 
observation. 

SYPHILITIC  ROSEOLA. 

No  other  infectious  erythema  possesses  the  same  importance  as( 
syphilitic  roseola;  which  is  accordingly  selected  for  a  special  descrip- 
tion. It  is  the  most  common  of  the  cutaneous  syphilides  and  con- 
sists of  an  eruption  of  spots,  at  first  of  a  peach  blossom  color,  of  a 
deeper  pink  after  a  few  days,  of  nummular  size,  rounded  or  oval 
shape  and  indefinite  margins;  these  spots  being  at  no  time  either 
squamous  or  pruritic.  This  eruption  is  scattered  indiscriminately 
on  the  flanks,  the  chest,  the  back  and  the  abdomen,  sometimes 
extending  to  the  neck,  the  limbs  as  far  as  the  palms  and  soles,  very 
rarely  to  the  face  where  it  is  observed  only  on  the  forehead. 

In  the  absence  of  early  and  radical  treatment,  it  usually  appears 
from  forty  to  fifty  days  after  the  chancre,  beginning  on  the  flanks 
and  hypochondriac  regions,  developing  in  a  fortnight  and  lasting 
from  three  to  six  weeks  or  two  months.  It  occasionally  fails  to  make 
its  appearance  even  in  cases  where  the  chancre  has  remained 
unrecognized  and  no  treatment  has  been  instituted.  Not  infre- 
quently it  escapes  the  patient's  attention  and  must  be  looked  for. 
Sometimes  it  is  so  profuse  and  high-colored  as  to  give  the  skin  a 
mottled  appearance. 

The  roseolar  elements,  especially  when  small,  of  lenticular  dimen- 
sions, may  cause  a  slight  protuberance,  as  the  result  of  some  con- 
gestive edema;  representing  urticarial  roseola.  The  form  in  which 
the  macules  develop  into  papular  syphilides  is  designated  as  papular 
roseola. 

There  may  be  a  recurrence  of  the  roseola  in  the  course  of  the  first 
or  second  year,  or  even  later.  These  recurrent  roseolas  are  usually 
rather  pale  and  composed  of  larger  and  less  numerous  spots,  which 
are  often  circinate  or  annular;  their  duration  is  apt  to  be  prolonged. 

Tertiary  roseola,  or  tertiary  erythema,  is  the  name  given  to  dull  red. 
non-squamous  and  non-infiltrated  spots,  polycyclic  or  circinate, 
occupying  the  trunk  and  limbs  and  very  rebellious  to  treatment. 
These  lesions  are  met  with  in  long-standing  syphilitic  cases  which 
have  been  subjected  to  energetic  and  prolonged  treatment.  They 
may  be  interpreted  as  the  attenuated  equivalents  of  tuberculo- 
ulcerative  syphilides. 

Syphilitic  roseola  differs  from  the  pityriasis  rosea  of  Gibert  and 


42  ERYTHEMA  AND   THE  ERYTHEMATA 

from  eczema  by  the  absence  of  desquamation  of  any  kind;  from  the 
balsamic  roseolas,  by  its  less  intense  color,  its  slow  development  and 
the  absence  of  itching.  Among  the  affections  capable  of  causing  real 
diagnostic  difficulties  may  be  mentioned  the  roseola  of  leprosy  and 
the  roseola  of  mycosis  fungoides,  but  these  are  very  rare  and  are  accom- 
panied by  other  symptoms  of  these  two  diseases.  Anti  pyrin  roseola 
is  likewise  objectively  identical,  but  is  the  least  common  of  anti- 
pyrin  eruptions  and  lasts  only  eight  to  ten  days.  The  most  ordinary 
practical  difficulty  results  from  the  macules  sometimes  remaining 
on  the  skin  after  a  pyodermatitis,  scabies,  or  pediculosis.  All  doubts 
will  be  cleared  up  by  the  history  and  the  topographical  distribution 
of  tile  lesions. 

Diagnosis. — The  diagnosis  of  syphilitic  roseola  should  always  be 
carefully  confirmed  through  the  demonstration  of  other  signs  of  the 
infection,  such  as  glandular  enlargement,  mucous  patches,  remains 
of  the  chancre,  alopecia,  headache,  etc.,  or  by  means  of  the  ^Yasse^- 
mann  reaction. 

Treatment. — Treatment  should  be  prescribed  only  when  the  diag- 
nosis is  positive;  specific  medication  suffices,  whereas  irritating 
topical  applications,  sulphur  baths  and  all  methods  which  congest 
the  skin,  usually  merely  aggravate  and  prolong  the  eruption. 


CHAPTER   II. 
URTICARIA. 

The  name  urticaria  is  applied  to  an  eruption  composed  of  peculiar 
elements  which  for  lack  of  a  special  denomination  are  described  as 
urticarial  patches  or  papules  or  wheals.  This  eruption  is  essentially 
pruritic  in  character. 

The  eruptive  element  of  urticaria  is  an  elevated  distinctly  outlined 
efflorescence,  light  pink  in  color  or  of  an  opalescent  white  with  a 
pinkish  areola;  of  a  rounded  or  oval  shape,  sometimes  polycyclic 
and  of  solid  consistence.  Its  dimensions,  usually  nummular,  vary 
from  the  size  of  a  lentil  to  that  of  a  more  or  less  extensive  surface. 

The  eruption  consists  of  an  extremely  variable  number  of  elements, 
appears  suddenly,  in  a  few  seconds,  is  transitory  or  ephemeral, 
vanishing  after  a  few  minutes  or  hours;  the  pinkish  color  fades,  the 
elevation  flattens  out  and,  with  some  exceptions,  no  trace  is  left 
behind. 

The  eruptive  element  is  typical,  but  in  spite  of  the  characteristic 
eruption,  urticaria  can  in  no  way  be  regarded  as  a  disease.  It  is 
often  a  simple  symptom,  a  cutaneous  reaction  which  may  be  provoked 
by  a  great  variety  of  causes.  It  is  sometimes  a  syndrome,  when  the 
eruption  assumes  the  behavior  of  a  pseudo-exanthematic  eruption 
and  is  accompanied  by  general  disturbances;  but  it  is  not  a  disease 
in  itself. 

It  cannot  be  overemphasized  that  a  fundamental  characteristic 
of  urticaria  is  that  it  is  invariably  associated  with  severe  itching, 
heat  or  formication,  so  that  scratching  becomes  imperative.  The 
pruritus  often  precedes  the  appearance  of  the  efflorescences;  it  is 
usually  more  diffuse  than  the  eruption. 

In  an  attack  of  urticaria,  the  skin  of  the  affected  regions  presents 
almost  invariably,  at  any  rate  temporarily,  a  congestive  tendency 
which  may  be  designated  as  urticarism;  owing  to  which  new  lesions 
may  be  provoked  by  scratching,  rubbing,  the  action  of  cold  or 
irritation  of  any  kind.  Jacquet  has  shown  that  no  new  lesions 
appear  under  really  occlusive  padded  dressings.  It  may  accordingly 
be  stated  that  in  urticaria  the  pruritus  is  primary  as  compared  to 
the  eruption.  Many  dermatologists  therefore  group  urticaria  under 
the  heading  of  pruritus. 

The  site  of  urticaria  is  extremely  variable;  it  is  localized  or 
regional  or  it  may  be  generalized;  it  affects  preferably  the  trunk  and 


11 


URTICARIA 


liml >s,  but  sometimes  also  the  palmar  and  plantar  regions,  the  face 
and  the  hairy  scalp.  In  regions  with  a  loose  cellular  tissue,  such  as 
the  eyelids,  the  prepuce  [the  lips],  etc.,  the  eruption  manifests  itself 
in  the  form  of  an  enormous  urticarial  edema,  with  diffuse  margins, 
rather  alarming,  but  transitory. 


Fig.  4. — Acute  urticarial  eruption,  on  the  flank  of  an  adult  man  (developing  in  the 
course  of  axillary  pyodermatitis) . 


The  mucous  membranes  may  be  invaded,  notably  the  mouth, 
pharynx,  and  larynx;  redness  and  edema  occur,  and  the  latter  may 
interfere  with  respiration.  Mention  has  even  been  made  of  urti- 
caria of  the  nasal  fossae,  the  bronchi  and  the  digestive  apparatus. 
This  is  imaginary  and  merely  a  theoretical  explanation  of  hay-fever, 
certain  forms  of  asthma  and  of  paroxysmal  diarrhea. 

The  general  phenomena  which  may  accompany  the  onset  of  certain 
very  severe  attacks  of  urticaria  consist  in  fever,  sometimes  high 
but  very  transitory  {urticarial  fever)  and  prostration,  with  more  or 
less  marked  digestive  disturbances. 

Varieties.  The  varieties  of  urticaria  are  numerous  and  are 
derived  from  the  morphological  aspect  of  the  lesions  or  the  course 
of  the  eruption.  The  configuration  of  the  eruptive  lesions,  discoid, 
annular,  circulate  or  linear;  as  well  as  their  porcelain  tint,  have  no 
special  importance.  However,  the  center  of  the  spots  may  assume 
;i  purplish  line,  resisting  digital  pressure;  this  is  hemorrhagic  urticaria, 
separated  merely  by  a  shade  from  purpura  urticans.  The  bloody 
infiltration  in  the  skin  in  these  cases  undergoes  the  usual  transfor- 
mation into  pigment,  so  that  the  elevations  leave  brownish  macules 
behind;  this  pigmented  urticaria  must  be  carefully  distinguished  from 
urticaria  pigmentosa  (p.  70o). 

The  appearance  of  a  small,  hard  and  persistent  papule  in  the  center 


ETIOLOGY  45 

of  the  urticarial  spots  characterizes  the  papular  urticaria  of  several 
authors.  This  is  described  in  this  book  under  the  name  of  strophulus 
(p.  141). 

In  certain  very  unusual  cases,  the  urticarial  elevations  become 
topped  by  a  blister  containing  a  serous  and  later  a  purulent  fluid 
which  dries  in  crusts.  This  bullous  urticaria  is  not  readily  distin- 
guished from  certain  forms  of  pemphigus  (p.  175).  [Both  papular 
and  bullous  urticaria  are  not  uncommon  in  the  urticarias  of  infants 
and  children.] 

The  eruptions  which  have  sometimes  been  described  as  urticaria 
perstans,  the  lesions  of  which  persist  for  months  or  years,  and  which 
must  not  be  confused  with  constantly  recurring  chronic  urticaria, 
are  probably  related  either  to  the  prurigos  (p.  498)  or  to  the  pre- 
mycotic  eruptions  (p.  657). 

Giant  urticaria  is  a  separate  clinical  form,  which  will  be  briefly 
discussed  further  on.  The  same  remark  applies  to  factitious  urticaria. 

The  behavior  of  urticaria  permits  the  distinction  of  an  accidental 
form,  instantaneously  produced  by  an  external  irritant;  an  acute 
form,  in  which  the  eruption  consists  of  a  single  attack,  or  a  few 
successive  or  overlapping  attacks,  so  that  the  patient  is  well  again 
in  twenty-four  hours,  in  two  or  three  days,  or  in  a  week;  and  a 
chronic  urticaria,  in  which  successive  attacks  occur  continuously, 
or  at  intervals,  during  months  or  even  years.  In  the  last  named 
cases  the  itching  becomes  a  real  torment,  disturbing  sleep  and 
exhausting  the  patient,  as  a  result  of  the  incessant  scratching,  the 
skin  becomes  covered  with  excoriations,  crusts,  and  pigmentations. 
The  condition  may  terminate,  according  to  the  age  of  the  patient, 
in  Hebra's  prurigo,  or  in  ordinary  diffuse  prurigo  (pp.  494  and  496). 

Etiology. — The  causes  of  urticaria  are  in  part  local,  direct  or 
determining;  and  in  part  general,  indirect  or  predisposing.  They 
may  become  associated  in  variable  proportion  in  producing  the 
eruption. 

It  will  be  readily  understood  that  a  very  active  direct  cause  may 
by  itself  alone  give  rise  to  urticarial  efflorescences,  in  all  persons 
indiscriminately;  on  the  other  hand,  in  very  strongly  predisposed 
individuals,  the  most  ordinary  and  trifling  irritant  may  produce  the 
eruption.    Between  these  two  extremes  all  variations  are  met  with. 

Authors  who  maintain  that  urticaria  should  be  considered  as  a 
disease  having  a  deep-seated  cause  in  the  organism,  refuse  to  include 
with  it  such  artificial  efflorescences  as  that  produced,  for  instance,  by 
the  stinging  nettle,  although  the  very  name  of  the  disease  is  derived 
from  that  plant  [urtica].  This  conception  has  certain  arguments 
in  its  favor,  but  I  cannot  accept  it  for  the  reason  that  the  eruption  is 
identical  in  urticaria  of  external  and  of  internal  origin  and  that  it  is 
impossible  to  draw  a  sharp  line  between  these  two  affections.    All 


46  URTICARIA 

urticarial  eruptions  are  therefore  grouped  together  in  this  book 
under  the  heading  of  urticaria. 

External  Causes. — Stings  produced  by  the  glandular  hairs  of 
nettles,  the  stings  of  mosquitoes,  bed-bugs  and  fleas,  contact  with  the 
hairs  of  processional  caterpillars,  with  medusae,  or  various  poisonous 
plants,  give  rise  after  a  few  seconds  to  severe  pruritus  and  slight 
reddening.  Next,  especially  on  scratching,  or  when  the  congested 
and  sweaty  skin  is  washed  with  cold  water,  an  eruption  of  accidental 
urticaria,  or  even  of  acute  generalized  urticaria  in  predisposed 
individuals,  occurs.  A  local  cause  should  therefore  be  looked  for 
in  the  first  place  in  cases  of  urticaria  as  in  any  pruritus. 

It  is  superfluous  to  enumerate  all  irritants  capable  of  inducing  the 
eruption  in  temporarily  or  permanently  susceptible  individuals. 
The  slightest  friction  or  contact  with  water  or  even  air  may  be 
sufficient. 

Internal  Causes. — Clinical  studies  of  the  manifold  conditions 
under  which  urticaria  is  observed,  has  led  to  the  following  conclu- 
sions: The  predisposing  factor  in  urticaria  was  supposed  to  be 
referable  to  somewhat  indefinite  nervous  states,  often  of  congenital 
origin  in  children  and  youthful  individuals,  of  acquired  origin  in 
adults,  due  to  mental  strain,  hysteria,  neurasthenia,  chronic  intoxi- 
cations, or  weakening  from  any  disease.  Violent  emotions,  anger, 
or  fear,  may  precipitate  a  crisis. 

Digestive  disturbances  play  the  principal  part  in  other  cases, 
especially  gastric  dyspepsia,  dilatation  of  the  stomach,  diseases  of 
the  liver,  habitual  constipation.  An  attack  of  indigestion,  or  par- 
taking of  certain  foods  or  drinks,  brings  on  the  eruption  in  some 
individuals,  the  following  substances  appearing  particularly  injur- 
ious; Deep-sea  fish,  crustaceans,  shellfish,  especially  mussels,  pork, 
game,  eggs,  preserves,  cheese,  ices,  strawberries,  raspberries,  wines, 
tea  and  coffee,  many  medicinal  agents,  etc. 

In  urticaria  ab  ingestis,  a  reflex  action  of  gustatory  or  gastric 
origin  has  sometimes  been  assumed  on  account  of  the  very  brief 
period  before  the  onset  of  the  attack.  The  reflex  may  perhaps  also 
start  from  the  genito-urinary  organs,  according  to  the  older  views. 

The  urticaria  from  abnormal  intestinal  fermentations,  from  renal 
or  hepatic  insufficiency,  from  gout,  pregnancy,  etc.,  was  interpreted 
as  autotoxic,  while  the  urticarial  eruption  which  sometimes  precedes 
or  accompanies  the  eruptive  fevers,  intermittent  fever,  etc.,  was 
considered  as  infectious  urticaria. 

It  was  known  finally  that  several  varieties  of  urticaria  may  occur 
in  blood  diseases,  leukemias,  etc. 

Jn  the  last  few  years,  however,  the  subject  has  taken  on  another 
aspect  through  laboratory  and  experimental  investigations  along 
the  line  of  anaphylaxis  (p.  460),  as  will  be  discussed  further  on. 


PATHOGENESIS  47 

The  fact  has  now  been  established  that  the  majority  of  urticarias 
are  due  to  anaphylaxis. 

Pathogenesis. — The  eruption  of  urticaria  obviously  results  from  a 
local  congestion  of  the  cutaneous  vessels  with  serous  exudation  espe- 
cially in  the  papillary  body,  sometimes  extending  to  the  hypoderm 
and  more  rarely  to  the  epidermis.  The  firmness  of  the  urticarial 
wheal,  its  pallor  resulting  from  the  compression  of  the  bloodvessels 
and  the  cleavage  of  the  epidermis  in  the  bullous  form  are  proof  that 
the  plasma  is  exuded  under  high  pressure. 

It  should  be  kept  in  mind  that  toxic  or  infectious  erythema  may 
be  urticarial,  so  that  no  sharp  line  can  be  said  to  exist  between  the 
two  eruptive  types  of  erythema  and  urticaria.  Histology  furnishes 
no  data  to  explain  the  phenomenon  of  urtication.  In  simple  primary 
urticaria,  an  excised  segment  usually  presents  no  lesion,  provided 
the  blood-pressure  and  edema  have  disappeared ;  sometimes,  a  slight 
local  polynucleosis  is  noted.  [Gilchrist  has  found  distinct  evidences 
of  inflammatory  changes  even  in  the  most  recent  wheals.] 

As  to  the  pathogenic  mechanism,  Torok  and  Vas  have  shown  that 
the  fluid  exudate  in  urticaria  contains  more  albumin  than  that  of 
the  mechanical  edemas  and  is  analogous  to  that  of  the  inflammatory 
exudates.  The  inflammatory  or  angioneurotic  character  of  the 
urticarias  has  been  discussed  by  several  foreign  authors.  Torok 
and  Philippson  successfully  produced  experimental  urticaria  in 
dogs,  by  inserting  into  the  cutis  capillary  tubes  filled  with  various 
substances  among  which  may  be  quoted:  peptones,  pepsin,  trypsin, 
cadaverin,  putrescin,  morphin,  atropin,  antipyrin,  antidiphtheritic 
toxin,  staphylococcus  toxin,  etc.;  hot  water,  formic,  oxalic  and  uric 
acids,  syntonin,  casein,  etc.,  are  said  to  be  less  active;  while  glyco- 
coll,  asparagin,  purin  derivatives,  bilirubin,  etc.,  are  apparently 
inactive.  Possibly  some  of  these  substances  which  act  in  concen- 
tration also  play  a  part  when  they  circulate  in  even  infinitesimal 
dilution  in  the  blood. 

More  widely  applicable  and  more  conclusive  are  the  experiments 
which  have  demonstrated  the  anaphylactic  character  of  the  major- 
ity of  urticarias.  For  those  which  are  produced  by  the  sera  (page 
477),  proof  has  been  furnished  by  Arthus,  Theobald  Smith  and 
others.  Reasoning  by  analogy,  the  same  mechanism  has  been 
invoked  in  all  cases  where  injection  or  absorption  of  a  foreign 
albumin  enters  into  consideration.  Widal,  in  collaboration  with 
Abrami,  Brissaud  and  Joltrain,  has  shown  that  in  an  attack  of 
alimentary  urticaria,  the  cutaneous  phenomena  are  preceded  by 
a  set  of  blood  and  vascular  phenomena,  an  actual  "hemoclastic 
crisis,"  identical  with  that  of  anaphylactic  shock;  a  fall  of  blood- 
pressure  and  a  rapid  leukopenia  being  its  essential  features.  More- 
over, the  transmission  of  passive  anaphylaxis  to  guinea-pigs  has  been 


48  URTICARIA 

successfully  carried  out  by  Bruck,  for  urticaria  due  to  pork,  and 
for  the  eruption  following  mussels,  by  Flandin  and  Tzanck  working 
in  my  laboratory.  The  watery  fluid  of  hydatid  cysts,  which  causes 
urticaria  and  sometimes  grave  symptoms  when  effused  into  serous 
cavities,  although  it  is  not  poisonous  has  been  shown  to  produce 
anaphylaxis,  by  Chauffard,  Boidin,  Laroche  and  Deve. 

Tims  it  becomes  extremely  probable  that  under  a  large  number 
of  conditions,  the  susceptibility  to  urticaria  consists  in  an  ana- 
phylactic state  and  that  the  determining  cause  merely  liberates 
the  eruption. 

Treatment. — In  the  first  place,  it  is  necessary  to  determine  that 
the  urticaria  does  not  depend  upon  an  external  cause,  parasitic 
or  other.  Acute  attacks  are  suggestive  of  some  article  of  food; 
and  a  purgative  and  a  strict  diet  based  on  the  list  of  presumably 
harmful  substances  (see  Therapeutic  Notes),  with  some  local 
applications  may  constitute  sufficient  treatment. 

In  the  case  of  chronic  urticaria,  it  behooves  the  physician  to 
investigate  with  care  the  general  disturbances  so  as  to  remedy  these. 
Thorough  hygiene  of  the  nervous  system  and  a  strict  alimentary 
regimen,  sometimes  a  closely  prescribed  diet,  are  imperative. 

Internal  medication  may  be  required,  such  as  calcium  salts, 
ferments  or  yeasts,  ichthyol,  salicylates,  alkalis,  mineral  waters 
or  intestinal  irrigations.  The  subcutaneous  injection  of  0.5  mg. 
of  adrenalin  often  attenuates  the  crises  and  repeated  applications 
have  cured  a  few  cases.  [Immediate  relief  is  often  obtained  by 
the  subcutaneous  injection  of  0.01  gm.  of  pilocarpin  muriate.] 

The  remarkable  efficacy  of  serotherapeutic  treatment  in  some 
cases  of  urticaria  has  attracted  attention  to  the  study  of  the  differ- 
ent forms  of  this  method,  but  its  results  are  not  constant.  Some- 
times a  rapid  cure  has  been  obtained  by  copious  venesection  followed 
by  intravenous  injection  of  physiological  salt  solution,  by  the 
injection  of*  serum  from  a  healthy  person,  by  autoserotherapy,  by 
the  injection  of  animal  serum  in  very  minute  doses.  The  need  of 
caution  in  the  employment  of  these  remedies  cannot  be  overempha- 
sized, as  they  are  liable  to  aggravate  the  trouble.  The  procedures 
designated  to  establish  an  anti-anaphylactic  state  have  not  yet  been 
formulated. 

External  measures,  although  constantly  demanded  by  the  patient 
for  the  relief  of  the  pruritus,  are  of  minor  importance.  Baths  and 
douches,  it  is  well  to  know,  often  aggravate  the  trouble;  and 
similarly  ointments.  Soothing  acid  or  alcoholic  lotions  are  prefer- 
able and  should  be  applied  warm  or  cold,  or  rather  lukewarm,  with 
a  decoction  of  slippery  elm,  lime,  or  chamomile,  or  with  a  solution 
of  vinegar,  lemon- juice,  camphorated  alcohol,  carbolized  glycerin, 
menthol,  thymol,  resorcin,  etc.,  followed  by  abundant  applications 


URTICARIA  FACTITIA,   OR  DERMOGRAPHISM  49 

of  neutral  powders.  The  hygiene  of  the  skin  requires  some  atten- 
tion; the  underclothing  should  be  light,  of  fine  smooth  texture  and 
must  not  rub  or  press  on  the  skin. 

Whatever  the  cause  of  the  urticaria,  the  treatment  should  not  be 
schematic  but  should  be  specially  adapted  to  the  requirements 
of  the  case. 

GIANT   URTICARIA. 

Under  this  name,  or  that  of  acute  circumscribed  edema  of  Quincke, 
an  affection  has  been  described  which  manifests  itself  by  the  sudden 
appearance  of  edematous  infiltrations,  usually  fairly  well  outlined, 
firm,  pinkish  or  porcelain-white  in  the  center,  with  a  rose-colored 
periphery.  These  infiltrations  have  the  size  of  a  hazelnut,  walnut, 
or  even  an  orange;  their  elevation  may  amount  to  several  centi- 
meters; they  are  the  seat  of  a  sensation  of  tension,  burning  or 
itching.  They  may  appear  at  any  point  of  the  integument  or 
even  of  the  mucous  membranes,  although  the  face  and  the  region 
of  the  genital  organs  are  the  seats  of  predilection. 

The  attack  comes  on  suddenly,  often  during  the  night,  without 
prodromata  or  with  some  malaise  and  a  slight  fever;  a  single  eleva- 
tion, or  a  small  number,  appear  and  persist  for  a  few  hours,  at  most 
two  days.  The  attacks  may  be  periodically  repeated  or  they  may 
be  separated  by  intervals  of  variable  length. 

This  affection  persists  for  years,  associated  or  not  with  common 
chronic  urticaria;  it  finally  disappears,  sometimes  to  become 
replaced  by  other  pathological  manifestations.  Its  possible  locali- 
zation in  the  upper  respiratory  passages  represents  the  only  danger- 
ous element.  Also,  according  to  the  seat  of  the  edema,  the  patient 
may  be  disfigured  for  a  few  hours. 

Etiology. — The  etiology  is  the  same  as  that  of  chronic  urticaria. 
There  exist  intermediate  cases  between  this  and  Quincke's  edema. 

The  paroxysms  sometimes  follow  overeating,  errors  in  diet, 
nervous  overstrain  or  the  action  of  cold.  In  the  interval,  the 
patient  may  enjoy  excellent  health. 

Treatment.- — The  treatment  follows  that  of  ordinary  urticaria. 
Simple  calcium  chloride,  systematically  administered,  in  courses, 
has  repeatedly  proved  entirely  successful  in  my  experience. 

URTICARIA  FACTITIA,  OR  DERMOGRAPHISM. 

It  has  been  stated  above  that  in  most  cases  of  urticaria,  the 
eruption  can  be  provoked  at  the  time  of  the  attacks  by  scratching 
or  other  cutaneous  irritations.  Dermographism  is  an  altogether 
different  phenomenon.  In  certain  individuals,  a  mechanical  irri- 
tation, especially  forcible  friction  with  a  blunt  point  gives  rise  to 
4 


50 


URTICARIA 


a  special  cutaneous  reflex,  a  non-pruritic  urticarial  elevation.  A 
very  brief  stage  of  anemia  with  prominence  of  the  hair  follicles, 
is  followed  by  the  appearance  of  a  bright  pink  line,  which  widens 
to  1  to  2  cm.,  the  middle  becoming  raised  in  less  than  a  minute  in 
the  form  of  a  ridge.  At  the  end  of  five  minutes  this  ridge  may 
attain  a  height  of  3  to  1  mm.  and  a  breadth  of  1  cm.;  the  phenome- 
non usually  lasts  from  fifteen  to  twenty  minutes  or  sometimes 
several  hours.  Although  electrical  stimulation  or  other  irritations 
may  also  cause  its  appearance,  a  mechanical  action  is  most  effec- 
tive. Friction  over  the  affected  region,  after  the  complete  sub- 
sidence of  the  phenomenon,  may  cause  the  reappearance  of  the 
writing  or  designs  which  had  been  traced  on  the  skin. 


lographism 


Dermographism  is  observed  especially  on  the  trunk  and  on  the 
first  segments  of  the  limbs.  It  is  rare  in  the  face,  but  is  said  to 
have  occurred  on  the  buccal  mucosa. 

Dermographism  is  one  of  the  stigmata  of  the  neurotic  constitu- 
tion. It  is  met  with  in  hysterical  individuals,  in  epilepsy,  in  20  per 
cent,  of  the  insane,  especially  among  idiots  and  constantly  in 
catatonia ;  furthermore,  in  the  victims  of  lead  poisoning  and  chronic 
alcoholism,  especially  in  consumers  of  aromatic  liquors.  In  the 
spring,  during  the  menstrual  periods  and  after  emotions  or  fatigue, 
dermographism    is  the  most  marked.     It   is  noteworthy  that  it 


TREATMENT  51 

does  not  often  occur  in  association  with  common  urticaria.  Its 
name  of  pseudo-urticaria  is  derived  from  the  absolute  objective 
identity  between  the  dermographic  elevation  and  the  urticarial 
wheal.  The  suggestion  has  been  made  that  the  mysterious  aspect 
of  this  phenomenon  may  have  led  to  its  being  used  in  former  days 
in  the  tricks  of  sorcerers.  At  the  present  day,  malingerers  have 
utilized  it  for  the  simulation  of  some  other  eruption. 

Treatment. — The  treatment  consists  in  attention  to  hygiene,  if 
necessary,  and  care  of  the  general  condition. 


CHAPTER   III. 
PURPURA. 

The  name  purpura  is  applied  to  an  eruption  of  spontaneous 
hemorrhagic  spots.  The  spots  of  purpura  are  of  a  bright  or  bluish 
red  and  do  not  disappear  under  pressure  of  the  finger;  they  are 
usually  of  rounded  shape,  flat  or  slightlv  elevated,  of  variable 
extent,  more  or  less  numerous,  but  always  multiple. 

Petechia  is  the  term  in  use  for  the  description  of  small  punctiform 
or  lenticular  lesions;  they  sometimes  surround  the  pilo-sebaceous 
orifices.  Ecchymoses  are  more  extensive  and  irregular;  they  vary 
in  size  from  that  of  a  coin  to  that  of  the  hand,  or  more.  A  less 
common  term,  vibices,  designates  more  elongated  or  striated 
purpuric  spots. 

After  a  few  days  or  weeks,  depending  on  their  size,  these  hemor- 
rhagic spots  fade  away,  after  having  passed  through  the  same 
shades,  purplish,  brownish,  greenish  and  yellowish,  as  the  traumatic 
ecchymoses. 

Petechia1  are  highly  characteristic,  being  necessarily  spontaneous; 
ecchymoses  may  have  been  produced  by  a  forgotten  or  wilfully 
denied  traumatism,  sometimes  very  insignificant  in  the  victims  of 
hemophilia. 

Purpuric  spots  must  not  be  confused  with  vascular  nevi,  which 
are  of  indefinite  duration;  nor  with  the  spots  of  erythema,  which 
fade  away  under  pressure  of  the  finger. 

The  combination  of  erythema  with  different  varieties  with  pur- 
pura, either  in  the  same  spot  as  the  hemorrhages  or  coincidently  in 
the  same  region,  is  not  unusual.  The  purpuric  spots  may  also  be 
urticarial  at  the  onset  (purpura  urticans)  or  become  complicated 
by  urticaria. 

We  must  therefore  admit  an  obvious  relationship,  transition- 
forms  and  various  combinations,  between  purpura,  erythema  and 
urticaria  (such  as  erythema  nodosum  contusiforme,  urticaria  hemor- 
rhagica, etc.). 

The  term  purpura  should  not  be  applied  to  occasional  hemor- 
rhagic  eruptions,  such  as  occur  in  smallpox,  herpes  zoster,  eczema, 
pemphigus  and  the  pyodermatitides.  Such  conditions  are  properly 
described  as  hemorrhagic  variola,  etc. 

The  eruption  of  purpura  comes  on  in  sudden  or  prolonged  attacks, 
which  arc  frequently  successive.     The  attack  may  be  preceded  by 


CLINICAL  FORMS  53 

inflammatory  local  edema,  sometimes  lymphangitic,  of  short  dura- 
tion and  accompanied  by  heat  or  pruritus,  or  it  may  occur  without 
the  patient's  knowledge.  The  affected  region  appears  irregularly 
dotted  with  lesions,  all  of  the  same  size  or  of  different  sizes,  of 
the  same  age  or  at  different  stages  of  their  development. 

The  distribution  of  purpura  is  often  more  or  less  symmetrical; 
the  lower  limbs  are  most  commonly  and  sometimes  alone  affected, 
or  sometimes  all  the  extremities  are  involved.  The  eruption  may 
occupy  any  location  and  may  even  invade  the  mucous  membranes, 
where  it  is  apt  to  assume  the  form  of  blood  blisters  which  rupture 
and  give  rise  to  hemorrhage. 

In  some  cases  of  purpura,  it  is  possible  to  produce  a  hemorrhagic 
spot  through  moderate  pressure  on  the  skin  with  a  blunt  point 
(provoked  purpura),  or  an  eruption  of  petechia?  through  the  tempo- 
rary constriction  of  a  segment  of  the  limb  (tourniquet  purpura) . 

Clinical  Forms. — The  eruption  of  purpura  is  sometimes  merely 
a  commonplace  symptom  of  several  pathological  conditions;  these 
cases  are  described  as  secondary  purpuras.  Again,  it  may  form 
part  of  one  of  the  syndromes  designated  as  primary  purpuras, 
representing  their  most  salient  feature. 

As  a  matter  of  fact,  purpura  occurs  under  very  different  condi- 
tions; occasionally  ia  the  midst  of  health  and  without  an  appreciable 
determining  cause;  or  as  a  sequel  of  overstrain,  or  after  intoxica- 
tions; or  in  the  course  of  definite  infectious  diseases  or  cachexias. 
It  may  furthermore  be  associated  with  a  train  of  general  phenomena, 
among  which  rheumatoid  pains,  gastro-intestinal  disturbances, 
fever,  general  malaise,  etc.,  are  especially  common. 

On  the  one  hand,  the  purpuric  eruptions  may  occur  without 
hemorrhage  from  the  mucosa?,  constituting  purpura  simplex.  On 
the  other  hand,  it  may  be  accompanied  by  very  profuse  epistaxis, 
bleeding  from  the  buccal  mucous  membranes,  especially  the  gums, 
metrorrhagia,  melena,  hematuria  or  visceral  hemorrhages,  consti- 
tuting purpura  hemorrhagica. 

This  division,  for  which  we  are  indebted  to  Willan,  can  only  be 
maintained  from  the  descriptive  point  of  view,  for  it  does  not 
correspond  to  a  difference  in  etiology;  a  simple  purpura  may  at 
any  time  become  transformed  into  purpura  hemorrhagica.  It  is 
not  even  in  harmony  with  the  prognosis,  purpura  hemorrhagica 
being  sometimes  benign  and  at  other  times  grave. 

It  seems  more  rational  to  base  the  establishment  of  the  clinical 
types  on  the  question  of  whether  the  purpura  is  a  simple  symptom 
or  whether  it  constitutes  a  syndrome. 

Great  differences  of  opinion  on  this  point  exist  among  authors. 
The  following  forms  are  generally  admitted,  although  under  different 
designations : 


:>i  PURPl  RA 


SECONDARY    PURPURAS. 

The  secondary  purpuras  arc  those  which  appear  as  an  ordinary 
symptom  or  epiphenomenon  in  the  course  of  a  large  number  of 
pathological  conditions.  They  possess  an  indicative  value,  but  are 
of  little  importance  in  themselves. 

Four  classes  of  these  purpuras  are  recognized: 

1.  Mechanical  "purpuras,  which  occur  on  the  limbs  under  the 
influence  of  prolonged  constriction,  or  at  any  point  of  the  body  in 
the  course  of  asystole  [in  a  disturbance  of  cardiac  compensation] 
or  of  lits  of  whooping-cough  or  attacks  of  epilepsy. 

2.  Toxic  purpuras,  which  may  be  provoked  by  certain  medicinal 
agents  such  as  phosphorus,  potassium  iodide,  mercury,  arsenic, 
antipyrin,  chloral,  salicylates,  quinin,  belladonna,,  ergot,  copaiva, 
etc.,  as  well  as  by  injections  of  antitoxic  sera,  bites  of  venomous 
serpents,   etc. 

3.  Secondary  purpura  of  the  acute  infection*  diseases,  such  as 
angina,  diphtheria,  scarlet  fever,  gonorrhea,  typhoid,  typhus, 
miliary  tuberculosis,  malaria,  etc. 

1.  Cachectic  purpuras,  observed  at  advanced  stages  of  serious 
diseases,  cancer,  tuberculosis,  Bright's  disease,  hepatic  cirrhosis, 
icterus  gravis,  pernicious  anemia,  the  leukemias,  etc.  The  erup- 
tion usually  comes  on  insidiously,  without  inflammatory  phenomena, 
sometimes  with  edema  and  occupies  chiefly  the  lower  extremities. 

The  group  of  cachectic  purpuras  is  really  most  heterogeneous 
and  many  cases  are  probably  referable  to  an  infection,  auto-intoxi- 
cation, nervous  lesions  or  anomalies  of  the  blood. 

Purpura  senilis-  of  Bateman  has  sometimes  been  grouped  under 
the  same  heading.  rl  nis  designation  is  applied  to  purpuric  spots 
which  occur  incessantly,  for  years,  without  general  disturbances, 
in  aged  individuals;  located  predominantly  on  the  forearms.  Unna 
and  Tasini  have  shown  that  these  cutaneous  hemorrhages  are  related 
to  senile  degeneration  of  the  skin. 

PRIMARY   PURPURAS. 

The  primary  purpuras  are  those  in  which  the  petechia'  and 
ecchymoses,  with  or  without  hemorrhages  of  the  mucous  mem- 
branes, represent  the  exclusive  or  principal  phenomenon.  Several 
types  are  recognized : 

1.  Rheumatoid  purpura  is  the  most  common;  it  is  identical  with 
Schoenlein's  peliosis  rheumatica  and  the  myelopathic  purpura  of 
Paisans. 

It  occurs  in  both  sexes  but  more  frequently  in  youthful  or  adult 
males  and  is  supposed  to  follow  on  exposure  to  damp,  cold,  fatigue, 


PRIMARY  PURPURAS  55 

overstrain  or  emotional  disturbances.  The  onset  is  often  marked 
either  by  a  sensation  of  fatigue  or  articular  pains  in  the  lower 
limbs,  or  by  a  more  or  less  extensive  transitory  edema  in  the  same 
regions,  or  finally  by  gastro-intestinal  disturbances.  Fever  is 
variable,  not  high  and  may  be  absent. 

The  rheumatoid  pains  are  arthralgic,  associated  or  not  with 
articular  swelling;  they  affect  the  knees  and  ankles  especially,  but 
may  extend  to  the  joints  of  the  upper  extremities. 

Sometimes  the  pain  is  muscular  or  neuralgic.  The  distinction 
between  these  rheumatoid  naiiis  and  those  of  acute  rheumatism  has 
been  emphasized  by  Besnier. 

The  gastro-intestinal  disturbances  consist  in  repeated  vomiting 
with  gastralgia,  in  intestinal  colics,  often  severe,  simulating  the  pains 
of  peritonitis,  or  accompanied  by  diarrheal  crises,  melena,  or  dys- 
enteriform  evacuation.  These  various  manifestations  precede  or 
accompany  the  eruption  and  are  temporary,  but  may  sometimes 
recur  in  the  course  of  the  disease.  Various  complications  have  been 
noted  on  the  part  of  the  serous  membranes  and  the  viscera. 

The  eruption  consists  of  petechia,  more  or  less  mixed  with  small 
ecchymoses;  it  affects  especially  the  lower  limbs  symmetrically 
(Fig.  6),  but  may  become  generalized,  beginning  with  the  upper 
limbs.  Not  infrequently,  it  is  polymorphous,  mixed  with  papular, 
nodular,  or  urticarial  erythema.  The  name  of  purpura  exanthe- 
matica  is  used  by  Laget  for  this  eruptive  complex. 

The  attacks  recur  at  very  irregular  intervals.  They  are  sometimes 
so  obviously  aroused  by  posture  or  walking  as  to  justify  the  expres- 
sion of  "orthostatic  purpura."  Periodical  attacks  coinciding  with 
the  menses  have  also  been  observed. 

The  majority  are  cases  of  purpura  simplex.  Hemorrhages  are 
rare,  but  may  supervene  in  the  course  of  evolution,  aggravating 
the  clinical  picture. 

The  duration  of  the  disease  is  ordinarily  a  few  weeks;  but  some 
cases  are  prolonged  for  several  months.  Recurrences  may  take 
place  at  irregular  intervals. 

The  severity  of  the  systemic  symptoms  varies  within  extreme 
limits;  sometimes  they  have  to  be  looked  for,  or,  on  the  contrary, 
they  may  have  the  appearance  of  a  grave  infection. 

Sporadic  scurvy,  only  rare  cases  of  which  are  now  met  with, 
differs  from  rheumatoid  purpura  by  its  etiology,  which  involves 
confinement  and  deprivation  of  fresh  foods,  as  well  as  by  the  swollen 
condition  of  the  gums  and  the  well-marked  anemia  and  asthenia. 
These  cases,  however,  may  be  interpreted  as  rheumatoid  purpura 
developing  in  a  prepared  soil. 

In  infantile  scuroy  or  Barlow's  disease,  the  ecchymosis  and  hemor- 
rhages of  the  mucous  membranes  are  far  from  constituting  the  most 


56 


Pl'RPT 'HA 


important  feature  of  the  clinical  picture,  in  which  painful  pseudo- 
paralysis [due  to  involvement  of  the  joints]  predominates. 

Although  apparently  primary,  the  cases  of  chronic  purpura, 
reported  especially  by  Hayem  and  his  school,  as  well  as  by  Millard 
and  others,  are  probably  of  autotoxic  origin  or  connected  with  a 
more  or  less  latenl  infection,  such  as  tuberculosis.  The  continuous 
or  intermittent  cutaneous  and  hemorrhagic  manifestations  mav  be 


Purpura  rheumatoides 


prolonged  for  ten  or  twenty  years,  the  prognosis  being  nevertheless 
regarded  as  relatively  favorable.  This  form  must  not  be  confused 
with  hemophilia,  which  is  congenital  and  hereditary  and  in  which 
the  coagulability  of  the  blood  is  always  markedly  diminished. 

I  nderthe  name  of  purpura  annularis  telangiectoides,  a  well-defined 
clinical  type  was  described  by  Majocchi,  in  1895,  and  has  since  been 
studied  by  several  authors.  It  consists  of  dull  red  spots,  symmetri- 
cally distributed  on  the  lower  limbs  especially,  at  first  telangiectatic, 


PRIMARY  PURPURAS  57 

then  hemorrhagic  and  becoming  ring-shaped  through  gradual  cen- 
trifugal extension.  Pasini  attributes  these  spots  to  endophlebitis 
of  the  small,  deep  veins  of  the  skin.  The  etiology  of  this  dermatosis 
is  entirely  unknown. 

2.  Primary  infectious  purpuras  are  those  in  which  the  general 
symptoms  indicate  an  infection  of  the  type  of  septicemia.  Besides 
relatively  attenuated  forms,  which  form  a  connecting  link  with 
rheumatoid  purpura,  there  occur  very  grave  forms,  such  as  the 
angiohematic  typhus  of  Landouzy  and  Gomot,  and  the  purpura 
fulminans  of  Henoch. 

Such  cases  may  begin  with  a  severe  initial  chill,  vomiting,  a  tem- 
perature of  40°  [104°],  typhoid  stupor,  delirium,  coma,  dry  tongue, 
albuminuria  and  sometimes  .icterus,  together  with  scattered  petechia 
and  ecchymoses  and  hemorrhages  from  various  avenues.  The  pur- 
puric lesions  may  become  gangrenous;  cellulitis,  purulent  arthritis, 
etc.,  may  occur.  Several  of  these  cases  have  recently  been  traced 
to  infection  by  the  meningococcus,  the  presence  of  which  in  the  blood 
and  in  the  spots  has  been  demonstrated  by  A.  Netter  and  Salanier. 
Death  may  follow  in  two  or  three  days  in  the  acute  variety;  or  in 
one  or  two  weeks,  in  the  typhoid  variety. 

3.  Abrupt  apyretic  purpura  hemorrhagica,  or  morbus  maculosus — 
two  typical  instances  of  which  were  published  by  WerlhofT — is  a 
rare  form.  According  to  a  generally  accepted  standard,  its  behavior 
is  as  follows: 

In  the  midst  of  health,  sometimes  after  an  emotion  or  slight 
traumatism,  often  without  prodromata  or  malaise,  without  fever, 
a  slight  nasal  or  gingival  hemorrhage  makes  its  appearance.  On 
the  next  day,  petechia  are  noted  on  the  lower  limbs,  then  larger 
scattered  ecchymoses  together  with  hemorrhages  from  various 
mucous  membranes.  After  ten  to  fifteen  days,  recovery  sets  in 
without  complications.  Neither  infection  nor  intoxication,  nor  a 
grave  lesion  of  the  blood  have  been  demonstrated  in  the  course  of 
the  disease. 

It  appears  more  and  more  probable  that  a  considerable  number 
of  the  clinical  forms  of  purpura  discussed  above,  notably  the  primary 
purpuras,  the  secondary  purpuras  following  infectious  diseases 
and  even  some  of  the  so-called  cachectic  purpuras,  do  not  constitute 
distinct  diseases,  but  merely  degrees  or  variations  of  the  same 
morbid  process.  Interpreted  in  this  manner  purpura,  simple  or 
hemorrhagic,  would  be  merely  the  consequence  of  various  acute  or 
chronic  infections,  causing  alterations  in  the  composition  of  the 
blood  and  vascular  or  visceral  lesions  which  in  turn  are  responsible 
for  the  different  aspects  of  the  syndrome. 


58  PURPURA 

Pathogenesis.  Purpura  is  observed  in  both  sexes,  at  any  age, 
under  a  great  variety  of  conditions  as  referred  to  above. 

Pathological  Anatomy. — Pathological  anatomy  teaches  that  the 
purpuric  spots  always  contain  an  effusion  of  blood,  with  its  white 
corpuscles;  situated  at  a  variable  level  in  the  meshes  of  the  derma 
or  hypoderm  up  to  the  papillae,  where  it  undergoes  the  usual  changes 
of  extravasated  blood.  Sack  has  shown  that  vascular  rupture  most 
frequently  occurs  in  the  small  veins  of  the  subdermal  plexus.  The 
vascular  walls,  although  various  changes  and  degenerations  have 
been  reported,  are  nearly  always  in  a  remarkably  intact  condition. 

In  the  absence  of  local  lesions  to  account  for  the  hemorrhages, 
different  general  conditions  have  been  invoked,  which,  however, 
do  not  exclude  one  another. 

In  the  circulating  blood,  the  number  of  red  cells  remains  normal, 
except  in  case  of  profuse  hemorrhages,  or  pernicious  anemia;  the 
number  of  white  corpuscles  is  rarely  changed  (leukemias) ;  the  blood 
platelets — according  to  Denys,  Hayem,  Bensaude  and  others,  con- 
firmed by  W.  Duke — may  become  very  scanty,  or  even  entirely 
disappear  (L.  Le  Sourd  and  Pagniez).  As  to  humoral  lesions,  a 
retarded  or  normal  coagulation  of  the  blood,  a  non-contracting  or 
imperfectly  contractile  and  friable  clot  and  an  increased  red  blood 
cell  resistance  has  been  noted.  The  "bleeding  time"  (W.  Duke) 
may  be  greatly  increased.  However,  these  various  phenomena  are 
inconstant;  their  importance,  mutual  relations  and  pathogenic 
significance  are  still  under  investigation. 

Viscera]  lesions  are  common.  Those  of  the  liver  and  kidney  may 
be  charged  with  having  prevented  the  destruction  or  the  elimination 
of  certain  toxins;  on  the  other  hand,  the  role  of  the  hepatic  function 
in  the  coagulation  of  the  blood  is  well  known.  Changes  in  the  intes- 
tinal tract  arc  frequently  found  in  the  purpuras,  as  shown  by  clinical 
observation  and  autopsies;  1  believe  that  the  intestinal  tract  is  often 
the  starting-point  of  the  infection  or  intoxication  to  which  the 
purpura  is  due,  perhaps  through  intermediation  of  the  liver  which 
is  damaged  in  transit.  A  form  of  abdominal  purpura  has  even  been 
described  (Henoch).  A  pathological  condition  of  the  suprarenal 
glands  and  hi Ivessel  glands  has  sometimes  been  held  responsible. 

The  role  of  the  nervous  system  is  shown  by  a  large  number  of 
facts.  The  rheumatoid  pains  characteristic  of  certain  primary 
purpuras  have  been  referred  to  above.  Petechial  eruptions  have 
been  observed  in  the  course  of  myelopathies  and  neuritis.  Straus 
has  noted  their  coincidence  with  the  fulminating  or  lightning  pains 
of  tabes.  There  are  cases  of  purpura  involving  only  one-half  of  the 
body,  or  even  in  exceptional  cases  assuming  a  metameric  or  radicular 
distribution,  proving  at  any  rate  a  localizing  influence  of  the  nervous 
system.     Spinal  puncture  sometimes,  but  not  invariably,  reveals  a 


PRIMARY  PURPURAS  59 

lymphocytosis  of  the  cerebrospinal  fluid.  Finally,  Grenet  has  suc- 
ceeded in  the  experimental  production  of  purpura  in  rabbits,  by 
first  damaging  the  liver  and  then  injecting  toxins  into  the  spinal 
cord. 

The  possible  effect  of  intoxications  is  illustrated  by  the  existence 
of  the  toxic  purpuras,  which  have  been  mentioned.  A  probable 
influence  of  auto-intoxications  and  perhaps  of  microbic  toxins  may 
be  inferred. 

Infection,  as  I  have  intimated,  is  probably  responsible  for  all  the 
non-toxic  forms  of  purpura.  Originally  asserted  by  Hayem,  this 
fact  has  been  established  by  clinical  observation  and  laboratory 
research  in  a  group  of  cases  and  is  very  probable  for  the  remainder, 
including  the  so-called  neuropathic,  dyscratic,  or  cachectic  purpuras. 
Moreover,  the  literature  contains  a  very  considerable  number  of 
cases  where  the  staphylococcus,  streptococcus,  pneumococcus,  pyo- 
cyaneus,  meningococcus,  etc.,  have  been  demonstrated  either  in 
the  purpuric  spots  or  in  the  circulating  blood.  These  facts  tend  to 
show  that  a  variety  of  infections  may  manifest  themselves  in  the 
clinical  picture  of  purpura. 

It  is  possible,  but  by  no  means  an  established  fact,  that  there 
exists  a  specific  microbe,  more  apt  than  others  to  produce  the  patho- 
logical picture  of  infectious  purpura.  This  would  serve  to  explain 
the  cases  of  epidemic  and  contagious  purpuirc  fever,  mentioned  by 
some  authors,  the  occurrence  of  which,  however,  is  somewhat 
doubtful. 

Treatment.— Any  case  of  purpura,  even  when  its  onset  is  appar- 
ently most  harmless,  must  be  carefully  watched,  as  it  is  impossible 
to  foretell  when  and  how  it  will  end.  These  patients  should  accord- 
ingly be  put  at  rest,  under  good  hygienic  conditions,  on  strict  diet 
and  in  the  open  air  if  possible.  For  the  control  of  the  hemorrhages, 
the  old  medication  with  acids,  ratanhia,  hamamelis,  ergotin,  iron 
perchloride,  is  now  abandoned,  experience  having  shown  them  to  be 
utterly  useless.  They  have  been  replaced  by  modern  agents,  such 
as  gelatin,  calcium  chloride,  injections  of  peptones  and  blood-sera, 
hepatic  and  suprarenal  extracts,  adrenalin,  pituitrin,  etc. 

The  results  obtained  in  the  treatment  of  hemophilia  and  hemo- 
globinuria have  led  to  experimentation  with  methods  acting  on  the 
equilibrium  of  the  blood,  modifying  its  coagulability  and  producing 
what  Widal  has  described  as  the  "hemoclasic  crisis."  Injections 
of  horse-serum,  in  large  amounts,  or  in  moderate  or  minute  repeated 
doses,  as  well  as  autoserotherapy,  have  their  advocates.  [A  careful 
search  must  be  made  for  occult  sources  of  infection  with  special 
attention  to  the  teeth  and  the  tonsils.]  These  methods,  which  do  not 
exclude  adjuvant  medication,  especially  with  calcium  salts,  have 
yielded  very  encouraging  results,  but  their  indications  have  by  no 
means  been  definitely  formulated. 


CHAPTER   IV. 
ECZEMA. 

The  eruption  known  as  eczema  is  not  characterized  by  a  single 
eruptive  element,  but  by  a  series  of  elementary  lesions  which  suc- 
ceed each  other,  combine  or  coexist  in  neighboring  localities.  These 
lesions  are  the  result  of  an  inflammatory  process,  affecting  the  epi- 
dermis and  cutis ;  an  epidermo-dermatitis,  comprising  several  stages 
which  are  of  equal  importance. 

Clinically,  these  stages  are  manifested  under  the  following  aspects: 
erythema,  resiculation,  exudation,  crust  formation,  lichenization  and 
desquamation. 

Histologically,  the  lesions  consist,  in  the  epidermis,  of  spongiosis, 
acanthosis  and  parakeratosis;  in  the  cutis,  of  congestion,  edema  and 
moderately  abundant  cellular  infiltration. 

This  definition  must  be  supplemented  by  mention  of  the  three 
characteristic  features  of  the  eruption:  its  usual  arrangement  in  spots, 
patches,  or  surfaces  with  irregular  outlines  (insular,  geographical  or 
archipelagous) ;  its  development  in  crops  or  relays,  with  a  tendency 
to  peripheral  extension  and  often  to  a  chronic  state  with  fresh 
exacerbations  and  its  more  or  less  pruritic  character. 

Defined  in  this  way,  the  eczematous  process  is  one  of  the  most 
easily  recognized.  It  must  be  appreciated,  however,  that  this  proc- 
ess is  not  limited  to  a  single  and  specific  dermatosis,  but  on  the 
contrary  represents  a  relatively  common  mode  of  reaction  of  the 
skin  toward  a  series  of  mechanical,  physical,  parasitical  and  microbic 
i  nit  ants.  This  reaction  must  be  considered  in  all  respects  as 
inflammatory. 

Eczema,  Eczematization,  Eczematosis.  —The  subject  of  eczema 
lias  become  extremely  complicated  and  much  confusion  has  been 
caused  by  the  application  of  the  term  eczema  for  some  time  to 
absolutely  different  conceptions.  Eczema  was  interpreted  by  Hebra 
and  the  Vienna  school  of  dermatologists,  as  a  very  common  poly- 
morphous affection,  which  may  at  any  time  be  artificially  produced 
in  any  person.  According  to  the  French  school,  on  the  other  hand, 
eczema  was  a  rare  disease,  especially  in  the  clinical  material  of 
hospitals,  incapable  of  being  artificially  produced,  since  it  implies 
the  existence  of  a  general  predisposition — altered  tissue-juices — 
a  diathesis.  Hence,  two  entirely  distinct  groups  of  facts  had  to  be 
dealt  with.     Besnier,  in  1S92,  was  perhaps  the  first  to  elucidate 


ECZEMA,  ECZEMATIZATION,  ECZEMATOSIS  61 

the  controversy  by  creating  the  word  eczematization  to  designate  the 
eczema  of  Hebra-Kaposi,  which  is  not  a  disease  but  an  eczematoid 
artificial  dermatitis.  The  eczema  of  French  writers,  on  the  contrary, 
is  a  true  disease,  which  although  having  multiple  causes  is  related  to 
a  peculiar  condition  of  the  individual;  this  disease  is  chronic  and 
recurrent.  The  eruptive  manifestation  of  eczematous  disease  is 
identical  with  that  of  eczematous  lesions,  or  eczematization. 

The  question  would  thus  seem  to  have  become  quite  clear,  but  on 
closer  examination  considerable  difficulties  of  interpretation  are 
encountered.  If  several  persons  be  subjected  to  the  same  external 
irritant,  for  example,  rubbing  with  spirits  of  turpentine  or  tincture 
of  arnica,  some  will  experience  at  the  injured  point  a  transitory 
erythema  or  a  dermatitis  in  the  form  of  eczematization  with  a 
marked  tendency  to  subsidence;  in  others,  this  dermatitis  will  be 
extensive  and  may  even  become  generalized,  then  healing  more  or 
less  rapidly;  and  finally,  in  others,  its  duration  will  be  prolonged, 
recurrences  supervening  on  slight  causes  or  even  in  the  absence  of 
an  appreciable  cause  and  this  abnormal  condition  may  occasionally 
persist  throughout  life. 

Several  suggestions  have  been  made  in  explanation  of  these 
differences  in  the  evolution  of  the  lesions.  It  has  been  claimed  that 
an  eczematization  produced  by  contact  with  an  irritant,  no  matter 
what  its  evolution  and  duration,  is  and  remains  an  artificial  eczema- 
toid dermatitis,  there  being  only  an  objective  and  apparent  identity 
between  it  and  the  disease  eczema  dependent  on  a  diathesis.  This 
interpretation  would  necessarily  lead  to  grouping  absolutely  similar 
clinical  pictures  under  different  headings  and  to  basing  the  diagnosis 
on  the  patient's  statements  or  on  an  estimate  of  the  irritative  proper- 
ties of  the  supposedly  provoking  causes. 

It  has  also  been  stated  that  an  ordinary  eczematoid  dermatitis 
may  become  transformed  into  a  specific  dermatitis;  but  this  can 
hardly  be  admitted,  as  it  is  not  known  wherein  the  specificity  of  the 
disease  eczema  lies. 

Obviously,  on  the  contrary,  the  persons  of  the  first  group  in  the 
above-mentioned  example,  were  in  a  state  of  physiological  integrity, 
investing  them  with  relative  immunity  toward  the  injurious  agent, 
whereas,  pathological  conditions  creating  a  morbid  tendency  existed 
in  the  others.  Those  who  were  affected  in  the  most  severe  and  per- 
sistent manner  were  eczematous  subjects  in  whom  a  local  irritation 
sufficed  to  bring  out  a  hitherto  latent  disease.  Although  this  is 
entirely  plausible,  it  must  be  added  that,  keeping  in  mind  the  very 
variable  evolution  of  eczematous  dermatitis  of  artificial  origin,  one 
is  forced  to  admit  an  entire  scale  of  subnormal  and  abnormal  states, 
creating  a  more  or  less  marked  predisposition  for  the  appearance, 
persistence  and  recurrence  of  the  eczematous  eruption. 


62  ECZEMA 

Thus  all  distinct  boundaries  or  fundamental  differences  between 
eczematization  or  artificial  eczematoid  dermatitis  with  a  rapid 

tendency  to  spontaneous  cure  and  true  eczema,  a  chronic  recurrent 
disease,  are  obliterated.  It  is  now  merely  a  question  of  degree  and 
there  remains  no  valid  reason  for  withholding  the  name  of  eczema 
from  any  eczematization,  whether  of  artificial  or  of  apparently 
spontaneous  origin. 

The  term  eczema  will  therefore  be  applied  in  this  book  to  all 
eruptions  corresponding  to  the  definition  at  the  beginning  of  this 
chapter.  This  name  will  be  supplemented  by  qualifying  adjectives, 
referring  to  the  momentary  objective  appearance  (vesicular,  exuda- 
tive, crusted  eczema,  etc.),  or  to  the  evolution  (acute,  chronic, 
recurrent  eczema),  or  to  the  apparent  etiology  (artificial,  occupa- 
tional, microbic  eczema,  etc.). 

I  propose  the  term  eczematosis  for  the  chronic  pathological  con- 
dition described  by  other  authors  as  constitutional  eczema,  eczema- 
disease  or  true  eczema. 

I  shall  speak  of  secondary  eczematization,  or  of  an  eczematized 
dermatosis,  when  a  dermo-epidermatitis  of  eczematous  type  becomes 
superadded  to  the  lesions  of  a  preexisting  dermatosis  (example: 
eczematized  prurigo,  eczematized  psoriasis,  etc.). 

Finally,  as  will  be  seen  in  the  next  chapter,  I  call  eczematides  the 
dry  eczemas,  the  eczema  seborrhoeicum  or  seborrheids  of  other 
authors. 

Pathological  Anatomy. — Eczema  being  an  inflammatory  patho- 
logical process  clinically  manifested  by  very  variable  objective 
appearances,  the  nature  of  their  process  must  be  studied  in  detail 
before  describing  the  manifestations. 

1 .  The  chief  lesion  of  eczema  is  an  edema  of  the  Malpighian  body; 
the  serous  fluid  infiltrates  between  the  epidermic  cells,  stretching 
their  connecting  filaments,  so  that  the  rete  assumes  an  appearance 
which  is  very  properly  denominated  as  a  spongioid  state,  by  I  Tina, 
and  as  spongiosis,  by  Besnier. 

2.  When  in  the  spongioid  state,  the  fluid  has  sufficient  pressure 
to  rupture  the  connecting  filaments  of  the  Malpighian  cells,  it  collects 
in  vesicles,  cavities  filled  with  a  transparent  fibrinous  plasma,  con- 
taining a  few  wandering  cells  and  bounded  by  epidermic  cells  which 
have  been  pushed  aside  and  sometimes  compressed.  These  vesicles, 
which  at  first  are  very  small,  originate  in  the  deep  layer  of  the  epi- 
dermis; they  increase  in  size  an  1  become  confluent  with  neighboring 
vesicles  until  they  are  visible  to  the  naked  eye  and  protrude  under 
the  horny  layer;  ultimately  vesicles  form  at  all  levels  in  the  rete; 
the  oldest  arc  pushed  up  toward  the  surface  by  the  outward  growth 
of  the  epidermis  and  new  ones  are  often  formed  beneath  them. 


ECZEMA,  ECZEMATIZATION,  ECZEMATOSIS 


G::i 


The  vesiculation  of  eczema  is  therefore  interstitial  and  dependent 
on  the  spongiosis,  therein  differing  from  the  vesiculation  of  zona, 
varicella,  etc. 

The  ultimate  fate  of  eczema- vesicles  is  variable;  they  terminate 
by  desiccation  or  rupture,  or  become  secondarily  infected. 
_  3.  The  first  contingency,  desiccation  without  oozing  or  suppura- 
tion, may  eventuate,  no  matter  what  the  size  of  the  vesicles,  in 
regions  where  the  epidermis  is  resistant.  It  gives  rise  to  tiny 
crusts  or  larger  crusts,  composed  in  variable  proportions  of  dried 
serum,  the  remains  of  parakeratotic  cells  and  collections  of  microbes. 
The  epidermis  reforms  below  and  the  crusts  are  shed.  Desiccation 
of  the  foci  of  spongiosis  is  the  rule  in  certain  forms  having  a  rather 
peculiar  clinical  appearance  and  course,  so  that  they  have  been 
separated  from  the  group  of  moist  eczemas  under  the  name  of  dry 
eczemas  or  seborrheal  eczemas.  They  will  be  described  further  on 
under  the  name  of  eczematides  (p.  90). 


Fig.  7. — Histology  of  eczema.  X  45.  A,  infected  vesicle;  B,  crust;  C,  parakera- 
tosis; D,  acanthosis;  E,  papillary  edema;  F,  vesicle;  G,  spongiosis;  H,  perivascular 
infiltration. 


4.  When  the  vesicles  have  ruptured  spontaneously  or  under  the 
influence  of  scratching  or  rubbing,  their  contents  are  poured  out 
externally  and  there  is  weeping  or  oozing.  In  weeping  eczema, 
the  escape  of  serous  fluid  is  often  prolonged,  without  production  of 
new  vesicles,  because  the  fluid  of  the  spongiosis  which  is  incessantly 
reproduced,  finds  a  way  of  escape  through  the  open  cavity  of  the 
ruptured  vesicles;  these  constitute  the  eczematous  pores.  The  process 
of  keratinization  being  altered,  as  will  be  shown  further  on,  a  rapid 
cicatrization  of  these  orifices  cannot  occur. 

5.  The  vesicles  of  eczema  may  be  microbic  from  the  start,  or  they 
may  be  originally  sterile.  In  the  latter  case,  they  are  easily  infected 
by  pyogenic  microbes,  which  find  them  an  excellent  culture  medium 


64  ECZEMA 

to  which  they  attract  an  abundance  of  polynuclear  leukocytes.  This 
is  known  as  impetiginization  (p.  162). 

In  these  infected  or  impetiginous  eczemas,  the  fluid  is  turbid  or 
purulent  and  dries  in  thick  mclicerous  crusts,  under  which  the 
epidermis  remains  deeply  eroded;  moreover,  the  increased  viru- 
lence of  the  microbes,  once  they  begin  to  grow,  leads  to  a  peripheral 
extension  of  the  lesions  and  their  remote  propagation  in  the  form 
of  microbic  eczema  or  of  true  impetigo. 

(>.  Coincidently  with  the  spongiosis,  the  Malpighian  edema  gives 
rise  to  the  change  of  keratinization  known  as  parakeratosis;  this  is 
characterized  by  the  disappearance  of  the  stratum  granulosum 
and  preservation  of  the  nuclei  in  the  cells  of  the  homy  layer,  which 
contains  less  fat  than  in  the  normal  state.  In  a  general  way,  the 
parakeratosis  controls  desquamation  and  it  accordingly  predomi- 
nates in  the  squamous,  lamellar,  psoriatiform ,  "craquele,"  ucorne," 
hyperkeratotic  eczemas,  etc. 

7.  The  spongiosis  and  the  vesiculation,  or  rather  more  probably  the 
persistence  of  the  causes  which  have  started  and  maintained  them, 
lead  at  the  end  of  a  certain  time  to  an  abnormal  multiplication  of 
the  Malpighian  cells,  hence  thickening  of  the  rete;  this  process  is 
called  acanthosis.  The  mterpapillary  pegs  are  enlarged  and  the 
papillae  are  proportionately  elongated  and  narrowed,  although  fre- 
quently edematous.  This  thickening  of  the  epidermis  and  of  the 
papillary  body  results  in  the  appearance  of  the  so-called  lichenoid 
eczema.  The  papillary  body  in  such  cases  is  usually  the  seat  of 
more  or  less  abundant  infiltration. 

8.  The  fluid  or  plasma  of  this  intra-epidermic  edema,  which  is 
seen  to  govern  practically  the  entire  eczematous  process,  is  obviously 
derived  from  the  cutis,  where  it  is  exuded  from  the  congested  and 
dilated  bloodvessels  of  the  papillary  body. 

The  epidermic  lesions  described  above  are  accordingly  preceded 
by  dermic  lesions,  consisting  of  hyperemia  and  edema  of  the  papil- 
lary body,  with  moderate  diapedesis  of  white  corpuscles  mixed 
with  a  few  red  cells,  which  accumulate  as  a  perivascular  infiltration. 
These  lesions  manifest  themselves  clinically  by  redness  and  swelling, 
the  symptoms  being  sometimes  slightly  marked,  but  in  other  cases 
constituting  the  most  obvious  phenomenon,  for  example  in  acute 
eczema  of  the  face  and  in  eczema  rvbrum. 

Of  the  various  elementary  anatomical  lesions  the  most  essential 
are:  spongiosis,  parakeratosis  and  acanthosis;  all  others  depend  on 
them.  They  may  become  combined  or  associated,  or  succeed  each 
other  in  such  a  way  as  to  give  rise  to  the  multiple  aspects  which 
eczema  may  assume.  It  must  be  kept  in  mind  that  the  qualifying 
terms  vesicular,  exudative,  squamous,  etc.,  do  not  designate  species 


ECZEMA,  ECZEMATIZATION,  ECZEMATOSIS  65 

or  even  varieties  of  a  distinct  type,  but  only  accidental,  temporary, 
or  more  or  less  persistent  phases. 

General  Etiology. — Considered  as  a  whole,  eczema  is  the  most 
common  of  all  cutaneous  affections.  Its  different  varieties  and 
localizations  make  up  nearly  one-third  of  dermatological  practice. 
[In  the  statistical  reports  of  the  American  Dermatological  Associa- 
tion, covering  about  three-quarters  of  a  million  dermatoses,  the 
eczemas,  including  eczematides,  comprise  about  20  per  cent,  of 
the  total.]  It  is  observed  at  all  ages;  during  early  childhood 
{infantile  eczema),  then  in  the  period  of  active  life  (occupational 
eczemas),  finally  in  the  stage  of  decline  of  organic  resistance  (senile 
eczema).  The  two  sexes  are  equally  susceptible  and  no  social  class 
is  immune. 

Its  causes  may  be  divided  into  external,  determining,  or  occasional 
and  internal  or  predisposing. 

External  Causes. — These  are  innumerable.  Nearly  all  local  irri- 
tants of  any  kind,  whose  moderate  influence  excites  erythema,  are 
capable  of  causing  eczema  when  their  action  is  augmented.  It 
must  be  noted,  however,  that  these  agents  are  eczematogenous 
to  a  variable  degree,  some  of  them  requiring  a  more  decided  pecu- 
liarity or  cooperation  of  the  organic  soil.  Predisposition  therefore 
has  a  bearing  not  only  upon  the  extent  and  duration  of  the  reaction, 
but  upon  its  character  also. 

Among  the  local  factors  of  eczema  must  be  mentioned  mechanical 
agents,  such  as  scratching;  physical  agents,  such  as  a  bright  light 
(Wilson's  eczema  solare),  heat  (eczema  caloricum);  and  countless 
chemical  irritants  (arnica,  turpentine,  phenol,  etc.).  The  majority 
of  these  injurious  factors  will  be  considered  in  the  chapter  on  the 
artificial  dermatoses  (XXIII).  Only  a  few  causes  of  particular 
interest  will  be  discussed  in  what  follows: 

Traumatic  Eczema  from  Scratching. — Eczema  causes  itching;  the 
scratching  of  the  eruption,  often  evidently  aggravates  it  and  in  some 
cases  may  be  responsible  for  its  extension  and  dissemination.  The 
question  arises  under  these  circumstances  whether  the  scratching 
served  to  transport  the  irritative  agent  or  the  microbes  which  had 
invaded  the  primary  focus,  or  if  the  skin  was  directly  eczematog- 
enous as  a  result  of  individual  prediposition.  This  dissemination 
was  regarded  by  Kaposi  as  the  effect  of  an  eruptive  reflex.  In 
another  group  of  cases,  scratching  is  primary  as  compared  to  the 
eruption;  this  is  the  case,  for  example,  in  pruritus  and  prurigo  (pp. 
481  and  488),  in  scabies  and  pediculosis,  also  I  believe  in  ichthy- 
osis, in  the  circulatory  disturbances  of  the  lower  limbs,  etc.  There 
exists  accordingly  a  true  traumatic  eczema. 

Parasitic  Eczemas. — Aside  from  pruritus,  or  under  conditions 
where  scratching  is  impossible,  parasitic  affections  may  give  rise  to 
5 


66  ECZEMA 

genuine  eczematization.  The  eczemas  of  scabies  and  pediculosis 
may  therefore  be  referable  either  to  scratching  or  to  the  virus  of 
the  parasites. 

In  trichophytosis  of  hairless  parts,  the  type  known  as  herpes 
circinaius  where  pruritus  may  be  almost  entirely  absent,  vesicles 
due  to  spongiosis  arc  observed,  followed  by  parakeratotic  desqua- 
mation. It  seems  to  me  justifiable  to  consider  these  as  eczematous 
and  to  attribute  them  directly  to  the  fungus  in  the  majority  of  the 
cases. 

Microbic  Eczemas. — The  question  as  to  the  part  played  by 
microbes  in  eczema  has  been  raised  only  relatively  recently. 
Twenty-five  years  ago  nobody  suspected  that  it  would  ever  arise; 
and  certain  modern  writers  have  probably  exaggerated  its  impor- 
tance. 

Unna  regards  eczema  as  a  microbic  dermatosis;  the  non-microbic 
affections  which  simulate  it  are  eczematiform  eruptions,  for  the 
most  part  artificial  dermatitides,  but  not  true  eczema.  The 
pathogenic  parasite  of  eczema  in  his  opinion  is  the  morococcus,  or 
the  morococcic  group;  this  is  the  name  applied  by  him  to  the  cocci 
which  are  found  in  mulberry-like  collections  under  the  roof  of  the 
vesicles.  Later  studies  have  identified  these  morococci  with  certain 
staphylococci  (p.  536). 

As  a  matter  of  fact,  it  has  been  established  by  careful  investi- 
gations- among  which  those  of  Veillon,  Sabouraud,  Halle  and 
Civatte  are  specially  mentioned  because  I  personally  assisted  in 
their  work — that  the  vesicles  of  dermatoses  which  must  be  regarded 
in  all  respects  as  eczemas,  are  primarily  amicrobie,  in  the  case  of 
artificial  eczemas  as  well  as  of  constitutional  eczemas.  These 
vesicles  may  become  infected  secondarily  by  the  ordinary  microbes 
of  the  skin. 

On  the  other  hand,  these  microbes  are  undoubtedly  capable  of 
exciting  the  reaction  of  eczematization  when  they  invade  the 
epidermis  through  the  agency  of  mechanical,  physical  or  chemical 
traumatization,  or  of  macerating  lesions  of  the  protective  horny 
layers;  or  of  an  abnormal  structure  of  this  layer  and  its  adnexa,  as 
occurs  in  ichthyosis  and  especially  in  kerosis  (XI);  or  of  local  or 
regional  circulatory  disturbances,  as  in  varicose  eczema;  and  finally, 
even  on  the  normal  skin,  when  they  have  acquired  an  increased  viru- 
lence through  culture,  in  impetigo  or  any  kind  of  wound,  fissure, 
fistula,  etc. 

In  eczema  of  war  /rounds,  described  by  me  as  paratraumatic 
eczema  (p.  ".">),  countless  instances  of  which  have  recently  been  met 
with,  these  various  conditions  were  generally  associated;  the  lesion 
of  the  epidermis  produced  by  iodin,  peroxide  water  or  other  anti- 
septics,  maceration   through   the  dressings,  local  circulatory  dis- 


ECZEMA,  ECZEMATIZATION,  ECZEMATOSIS  67 

turbances,  contamination  of  the  surface  by  the  pus  of  the  wound  or 
fistula,  combining  to  produce  a  genuine  type  of  microbic  eczema, 
more  or  less  impetiginous. 

The  facts  adduced  in  favor  of  the  general  parasitic  theory  of 
eczema  (Unna,  Leredde)  are  capable  of  other  interpretations. 
This  is  true  for  the  auto-inoculation  of  eczema  by  scratching,  etc.; 
its  recrudescence  from  imperfectly  extinct  foci;  the  peripheral 
extension  of  eczematous  patches;  the  identity  of  eczematous  pro- 
cesses irrespective  of  the  apparent  causative  agent;  and  the  some- 
times easy  curability  by  germicidal  local  applications.  But  these 
facts  nevertheless  constitute  a  set  of  impressive  arguments,  to  which 
may  be  added  a  few  observations,  due  to  Unna,  of  positive  inocu- 
lation of  microbic  cultures  derived  from  eczema,  which  produced 
an  eczematiform  lesion  in  healthy  inoculated  subjects. 

Briefly,  there  exists  an  assembly  of  clinical  data  and  laboratory 
findings,  which  prove  the  existence  of  an  eczema  of  microbic  origin 
and  character.  It  is  certain  that  various  microbic  species,  especi- 
ally belonging  to  the  staphylococcic  group,  may  be  eczematogenous. 
Perhaps  there  exists  a  still  unknown  microbe  which  more  than 
others  possesses  this  property.  At  the  present  writing,  however, 
it  is  not  possible  to  state  that  definite  species  of  microbes  corre- 
spond to  the  different  forms  and  types  of  eczema. 

We  are  especially  ignorant  of  the  degree  to  which  infection  is 
responsible  for  eczema  (for  example  in  the  artificial  dermatitides, 
in  eczema  from  scratching,  in  parasitic  eczema,  in  the  dissemina- 
tion of  eczema),  for  up  to  the  present  time  the  clinician  can  no 
more  recognize  in  a  given  case  whether  the  eczema  is  microbic  or 
not,  than  the  bacteriologist  can  determine  whether  the  detected 
microbe  is  primary  or  of  secondary  implantation. 

Internal  Causes. — The  general  pathological  conditions  usually 
met  with  in  cases  of  eczema,  and  which  may  be  suspected  of  being 
internal  or  predisposing  causes  of  this  dermatosis,  are  the  following : 
Heredity  is  often  invoked  and  is  said  to  be  either  direct,  when  the 
patient's  parents  were  likewise  eczematous,  or  indirect,  when  they 
suffered  from  obesity,  diabetes,  gout,  rheumatism,  lithiasis,  asthma 
or  migraine — briefly,  from  one  or  more  of  the  multiple  manifesta- 
tions of  the  nutritional  disturbance  known  [in  France]  as  arthritism. 
In  other  cases,  the  parents  were  inebriates,  or  exposed  to  various 
intoxications,  neurotic,  overworked,  etc. 

The  hygienic  antecedents  of  the  patient  himself  are  sometimes 
distinctly  bad,  whether  in  regard  to  the  abuse  of  stimulants,  alcohol, 
coffee,  tea,  tobacco,  etc.,  or  to  an  excessive  nitrogenous  diet,  over- 
eating, or  food  of  an  inferior  quality,  or  to  nervous  strain  in  all  its 
forms. 

Still  more  frequently,  auto-intoxications  are  responsible,  due  to 


fiS  ECZEMA 

gastric  or  intestinal  dyspepsia,  chronic  enteritis,  constipation,  etc. 
I  have  often  traced  the  trouble  to  a  bad  condition  of  the  teeth,  which 
at  the  same  time  causes  intoxication  by  the  putrefactive  products  of 
dental  caries  and  pyorrhea  alveolaris,  and  favors  abnormal  gastro- 
intestinal fermentation  through  incomplete  mastication  and  insali- 
vation  of  the  food.  Sometimes,  an  insufficiency  of  the  emunctories 
is  properly  held  responsible,  such  as  renal,  hepatic  or  intestinal 
insufficiency,  or  a  deficient  function  of  the  organs  of  internal  secre- 
tion. Whatever  may  be  the  pathogenic  mechanism,  the  relation 
between  the  dermatosis  and  these  functional  anomalies  is  entirely 
admisssible.  Urinary  examinations  unfortunately  yield  no  con- 
cordant results,  rendering  futile  the  hope  of  a  coming  "  urinary 
formula  of  eczema." 

Nutritional  disturbances,  the  hereditary  influence  of  which  has 
been  referred  to,  are  naturally  still  more  injurious  when  affecting 
the  patient  himself.  Sometimes,  as  the  patient  is  sure  to  empha- 
size, an  indisputable  alternation  or  substitution  is  noted  between 
the  attacks  of  eczema  and  certain  symptoms  such  as  asthma,  neu- 
ralgias, migraines,  bronchial  catarrhs,  or  digestive  disturbances. 
An  obstinate  progressive  eczema  frequently  precedes  by  several 
months  or  years,  and  so  to  say  intimates,  the  manifestation  of  a 
latent  visceral  cancer.  Diabetic  patients  are  evidently  predisposed 
to  eczema  which  not  uncommonly  begins  in  the  genital  regions. 

The  part  played  by  nervous  disturbances  is  equally  apparent. 
A  predisposition  to  eczema  is  created,  not  by  central  or  peripheral 
nervous  lesions,  but  rather  by  neurasthenia,  overstrain,  emotions, 
moral  shock,  grief,  etc.  We  do  not  know  if  the  nervous  system 
acts  through  a  vasomotor  or  trophic  disturbance,  which  would 
already  be  the  first  stage  of  the  eczematous  process;  or  if  it  acts 
merely  by  lowering  the  resistance  of  the  skin.  At  any  rate,  it 
seems  to  be  a,  loss  of  nervous  balance  which  brings  about  the  exces- 
sive irritability  of  the  eczematous  areas  which  show  themselves 
intolerant  toward  any  active  form  of  medication. 

A  reflex  nervous  action  on  the  skin  has  been  held  responsible 
for  the  temporary  predisposition  to  attacks  of  eczema  caused  by 
the  eruption  of  teeth,  by  menstruation,  pregnancy,  lactation,  the 
menopause,  etc. 

Regional  circulatory  disturbances,  like  those  accompanying  vari- 
cose veins,  for  example,  may  create  a  manifest  local  predisposition 
to  eczema. 

The  pathogenic  mechanism  according  to  which  these  manifold  causes 
net  i  necessarily  extremely  variable.  To  formulate  it  in  a  few  words, 
one  woul  I  be  tempted  to  say  that  as  the  process  is  inflammatory;  it 
represents  a,  defense  reaction  of  the  organism  against  the  injurious 
agents  which  attack  the  skin. 


ECZEMA,  ECZEMATIZATION,  ECZEMATOSIS  69 

Although  barely  admissible  for  the  external  causes  this  general 
idea  would  not  cover  the  internal  causes.  Too  many  decisive 
arguments  refute  the  theory,  which  is  still  occasionally  admitted, 
however,  according  to  which  the  skin  acts  vicariously  for  other 
emunctories  when  these  are  insufficient,  and  becomes  eczema- 
tous  under  the  influence  of  autogenous  poisons,  toxins  and  waste 
products,  which  seek  an  outlet  through  the  skin. 

A  rather  attractive  theory  was  advocated  by  Jacquet,  who 
claimed  the  intervention  of  a  nervous  reflex  action  of  trophic  char- 
acter. Visceral  lesions  or  internal  disturbances  are  supposed  to 
modify  the  nervous  impulses  transmitted  to  the  skin,  the  resulting 
trophic  change  enabling  the  skin  to  react  in  the  form  of  eczema 
against  strong  or  even  very  weak  external  irritants  which  would 
have  been  readily  tolerated  in  the  normal  state. 

The  majority  of  eczemas  undoubtedly  result  from  a  combina- 
tion, in  variable  proportions,  of  external  and  internal  factors.  It  is 
therefore  imperative,  in  a  given  case,  to  ascertain  through  careful 
clinical  analysis  the  "etiological  dominant"  and  the  accessory 
causes.  Only  when  this  requirement  is  complied  with  can  a  rational 
treatment  be  instituted  with  some  prospect  of  a  successful  out- 
come and  the  prevention  of  recurrences. 

Symptoms. — When  eczema  appears  suddenly,  on  a  rather  exten- 
sive surface,  or  during  an  exacerbation  in  the  course  of  chronic 
eczema,  certain  general  symptoms  may  be  noted,  such  as  digestive 
disturbances  and  especially  malaise,  excitement,  insomnia,  pros- 
tration and  a  slight  fever. 

The  eruption  is  essentially  polymorphous;  it  consists  of  redness, 
vesiculation,  exudation,  crusts  and  scales.  Its  most  characteristic 
feature  has  very  properly  been  stated  to  be  vesiculation,  but 
certain  eczemas  run  their  course  without  at  any  time  presenting 
demonstrable  vesicles. 

In  a  general  way,  but  remembering  that,  as  a  rule,  several  stages 
exist  together,  the  succession  of  the  phenomena  may  be  described 
as  follows:  At  the  onset,  vivid  reddening  with  diffuse  margins 
makes  its  appearance,  showing  a  very  finely  granular  surface  on 
inspection  with  a  lens,  with  more  or  less  edema,  tension  and 
pruritus;  representing  the  erythematous  stage.  It  is  rare  for  the 
redness  to  be  absent  or  to  escape  observation  and  for  the  vesicles 
to  appear  on  healthy  skin.  The  edematous  redness  sometimes, 
after  persisting  for  a  few  hours  or  a  day,  fades  away  and  leaves 
behind  a  fine  lamellar  or  furfuraceous  desquamation,  this  being 
observed  especially  in  the  face  and  the  genital  regions. 

As  a  rule,  a  few  hours  after  the  onset  of  the  attack,  a  large  crop 
of  very  superficial  vesicles  makes  its  appearance  on  the  erythem- 
atous surface,  with  transparent  contents,  from  the  size  of  a  needle- 


70 


ECZEMA 


point  to  that  of  a  pin-head,  very  close  together,  sometimes  becom- 
ing confluent  in  bullae  of  moderate  size;  this  is  the  vesicular  stage. 
On  the  hands  and  feet,  in  regions  where  the  epidermis  is  thick,  the 
vesicles  are  deeper  and  have  less  tendency  to  rupture.  They  may 
dry  in  crusts  which  are  gradually  eliminated. 

Usually  the  vesicles  do  not  exist  long  without  rupturing  spon- 
taneously or  under  the  influence  of  scratching  and  permit  the 
escape  of  a  clear,  slightly  stringy  fluid,  faintly  yellowish  or  turbid, 
stiffening  the  underwear  like  mucilage.  The  exudative  stage  may 
be  prolonged  for  several  days  or  even  weeks  in  different  cases 


Fig.  8.     Ecze 


sts,  showing  eczema  "pores." 


When  dressings  are  employed,  the  surface  of  the  skin,  on  removing 
the  dressings,  is  seen  to  be  red  or  a  vivid  pink,  smooth  and  perfor- 
ated with  superficial  round  or  polycyclic  erosions  from  which 
droplets  of  a  clear  sticky  serous  fluid  exude.  In  case  no  vesicles 
have  been  demonstrable,  these  erosions  which  are  the  eezematous 
pores  previously  referred  to,  represent  their  equivalent  (Fig.  8). 

In  the  absence  of  dressings  and  when  the  exudate  is  not  very 
profuse  it  dries  in  thin  yellowish  crusts,  or  in  brown  concretions 
when  a  little  blood  is  mixed  with  the  serum;  constituting  the  stage 
of  incrustation,  or  crusted  eczema. 


ECZEMA,  ECZEMATIZATION,  ECZEMATOSIS  71 

When  a  pyococcic  infection  becomes  implanted  on  the  eczematous 
surface,  which  is  not  uncommon  in  children  or  in  certain  regions 
of  the  body,  the  secretion  is  mixed  with  pus,  the  crusts  are  meli- 
cerous  or  grayish,  thicker  and  rougher.  The  surrounding  areas 
present  the  features  of  genuine  impetigo  and  the  case  becomes  one 
of  impetiginous  eczema  (p.  82). 

The  exudate  lessens  and  dries  up  after  a  variable  time;  the 
crusts  fall,  the  surface  becomes  covered  with  epidermis;  but  the 
new  horny  layer  remains  thin,  transparent,  slightly  adherent;  it 
cracks  through  desiccation  (fissured  eczema),  and  is  shed  in  lamellar 
or  furfuraceous  scales  which  are  incessantly  renewed. 

This  stage  of  desquamation  may  last  a  very  long  time.  The 
vesicles  are  very  apt  to  reappear  on  the  pinkish  scaly  surface,  sepa- 
rately or  in  groups,  continuously  or  in  crops,  with  a  renewal  of  the 
the  exudation  and  crust  formation. 

The  persistence  of  the  eczematous  process,  aggravated  by  scratch- 
ing, the  local  conditions  of  the  affected  region  and  the  general 
health  of  the  patient,  tends  to  produce  a  thickening  of  the  patches, 
with  elevation  and  induration.  The  normal  folds  and  lines  of  the 
skin  are  more  pronounced,  the  surface  is  dry  and  roughened,  scaly 
or  crusted.     This  condition  is  designated  as  lichenified  eczema. 

Eruptive  Varieties. — It  is  uncommon  for  the  various  stages  of 
the  eczematous  process  to  follow  a  regular  course;  as  a  rule,  they 
intermingle,  blend  and  exist  together  in  the  same  patient.  How- 
ever, it  must  be  admitted  that  certain  eczemas,  or  rather  the  eczemas 
of  certain  patients,  preferably  assume  one  or  other  objective  form 
and  persist  a  long  time  at  one  of  the  stages,  the  characteristics  of 
which  are  then  especially  well  marked. 

The  varieties  of  the  eruption  which  require  special  mention  are 
the  following: 

Vesicular  eczema,  with  constantly  renewed  vesicles,  occurs  espe- 
cially on  the  extremities.  A  special  type  has  been  distinguished 
under  the  name  of  dysidrosis. 

Exudative  eczema,  with  continuous  exudation,  is  observed  in 
gouty  or  obese  persons  especially  on  the  legs  and  arms,  in  the  new- 
born on  the  face,  sometimes  as  the  result  of  irritative  applications. 

Eczema  rubrum  is  the  form  in  which  the  reddening  is  intense 
(often  edematous)  and  does  not  completely  disappear  under 
pressure  of  the  finger,  indicating  an  abundant  diapedesis  of  red 
corpuscles  in  the  cutis.  It  occurs  in  extensive  patches  in  acute 
attacks,  or  is  persistent  and  indolent,  on  the  legs,  on  the  large  folds 
and  also  in  the  face. 

The  term  erysipeloid  eczema  is  sometimes  employed  to  desig- 
nate sudden  inflammatory  and  edematous  attacks,  sometimes 
followed  by  vesico-bullse,  affecting  especially  the  face  and  the  genital 


72  ECZEMA 

organs.  It  is  frequently  a  complication  of  a  dry  sluggish  eczema,  or 
the  result  of  an  artificial  local  irritation. 

Dry  eczema,  which  in  exceptional  cases  is  arranged  in  circum- 
scribed spots  or  patches,  often  polycyclic,  with  a  pinkish  scaly  sur- 
face, without  demonstrable  vesicles,  is  so  common  and  so  peculiar  in 
its  appearance  and  behavior  that  there  is  a  strong  temptation  to 
place  it  in  a  group  by  itself  ( seborrhoeic  eczema,  seborrheid,  psoriati- 
form  parakeratosis,  etc.).  It  will  be  discussed  at  length  under  the 
name  eczematides  in  the  chapter  on  the  erythemato-squamous 
dermatosis  (V,  p.  90). 

Squamous  eczema,  in  which  desquamation  is  abundant  and  con- 
tinuous, is  encountered  especially  in  individuals  or  regions  with 
defective  nutrition. 

Horny,  or  keratotic  or  tylotic  eczema  is  practically  limited  to  the 
plantar  and  palmar  regions  (XI,  p.  214). 

Lichenified  eczema,  often  circumscribed,  very  pruriginous  and 
chronic,  seems  to  be  likewise  connected  with  special  local  condi- 
tions. Its  differentiation  from  eczematized  prurigo  is  sometimes 
very  difficult  (p.  489). 

Imjietiginous  eczema,  more  common  in  children  and  in  the  arti- 
ficial dermatitides  may  give  rise  to  folliculitis,  furuncles,  adenitis, 
lymphangitis  and  abscesses,  in  short,  to  all  the  manifestations  of 
pyodermatitis  (p.  82). 

Varieties  of  Configuration. — The  distribution  and  extent  of  ecze- 
niatous  eruptions  are  extremely  variable  and  not  easily  classified. 
The  most  usual  configuration  is  in  form  of  spots,  patches  or 
surface  lesions  of  very  unequal  size  and  quite  irregular  contours, 
in  geographical  or  archipelagous  designs.  This  type,  designated 
as  amorphous  eczema  by  Devergie,  is  entitled  to  the  name  of 
eczema  uulgare. 

The  so-called  papulo-vesicular  eczema  of  Brocq  is  characterized 
by  the  fact  that  its  initial  element  is  a  small  papulo-vesicular 
elevation,  instead  of  a  simple  vesicle;  the  confluence  of  these  lesions 
results  in  patches  with  an  indurated  base.  The  eruption  is  gene- 
rally widely  scattered  and  develops  in  successive  crops.  There  is 
intense  itching  and  the  relation  of  this  form  to  the  prurigos  is  very 
evident  in  certain  cases.  Frequently,  however,  this  variety  is  com- 
bined with  eczema  vulgare  in  other  regions  of  the  body. 

Nummular  eczema  assumes  the  form  of  round  or  oval,  sharply 
circumscribed  spots,  which  are  sometimes  herpetoid  (I  nna)  or 
trichophytoid  (Sabouraud).  It  is  common  on  the  wrists,  on  the 
dorsal  aspect  of  the  hands  and  on  the  legs.  [The  patches  are 
remarkable  for  the  absence  of  peripheral  extension,  their  recurrence 
throughout  a  number  of  years  and  the  association  of  moderate 
eosinophilia.J 


ECZEMA,  ECZEMATIZATION,  ECZEMATOSIS 


73 


Varicose  eczema  and  paratraumatic  eczema  of  war  wounds  are 
noteworthy  on  account  of  their  distinctly  outlined  borders,  their 


Fig.  9. — Paratraumatic  eczema,  following  on  a  bullet-wound  of  the  right  arm 
of  three  months'  standing,  cured  in  fifteen  days.  Noteworthy  case  on  account  of  the 
arciform  and  syphiloid  configuration  of  the  eruption.  Note  the  central  cicatrization 
and  the  extension  by  vesico-pustules,  especially  on  the  convexity  of  the  border  at  the 
base  of  the  figure. 


Fig.   10. — Eczema  of  the  papulo-vesicular  type  on  the  forearm. 


usually  polycyclic  configuration,  and  their  continuous  peripheral 
extension;  they  are  apt  to  be  combined  with  impetigo. 


"4 


ECZEMA 


The  eczema  marginatum  of  Hebra  is  a  parasitic  epidermatitis  due 
to  the  epidermophyton  (p.  52  !  i. 

Disseminati  ■     eczema  will  he  considered  in  a  paragraph 

by  itself  (p.  s7  . 
'  Generalized   eczema   will    be   discussed    with    the  erythrodermas 
,,.  120    and  eczema  foUicuhriim   in  the  chapter  on  the  folliculoses 


ged  six  years 


Regional  Varieties.  On  the  scalp,  especially  in  children,  eczema 
is  often  incited  by  pediculi  and  associated  with  pyodermatitis;  in 
youthful  individuals  and  in  adults  it  is  ordinarily  a,  complication 
of  pityriasis  and  there  are  imperceptible  transitions  between  dry 
pityriasis,  steatoid  pityriasis,  dry,  exudative  and  crusted  eczema 
(see  Kerosis,  p.  196). 

In  the  beard  and  hairy  regions  the  same  relations  with  pityriasis 
are  noted.  The  eczema  may  be  of  the  exudative  type  and  often 
gh  es  i  ise  t"  p>  ococcic  \\  cosis. 


ECZEMA,  ECZEMATIZATION,  ECZEMATOSIS  75 

Orbicular  or  orificial  eczemas  are  dry  or  exudative,  often  very 
obstinate  and  are  caused  or  maintained  by  lesions  of  the  mucous 
membranes  and  corresponding  cavities;  they  have  been  interpreted 
as  of  reflex  origin.  On  the  lips,  a  bad  condition  of  the  teeth,  irri- 
tating tooth-pastes,  pharyngitis,  etc.,  may  be  responsible. 

Persistent  desquamation  of  the  red  border  of  the  lips  forms  a  special 
type  of  unknown  character  which  has  been  referred  by  some  writers 
to  psoriasis,  seborrhea,  etc. 

On  the  nostrils,  eye-lids  and  ears  conditions  are  involved  such 
as  chronic  coryza,  sinusitis,  ocular  disturbances  and  otitis  media 
or  externa;  in  eczema  of  the  vulva,  the  trouble  may  be  due  to 
diabetes,  cystitis,  vaginitis,  or  metritis;  in  eczema  of  the  anus,  to 
hemorrhoids,  fissures  or  constipation. 

Perigenital  and  peri-anal  eczema  very  frequently  follow  on 
pruritus  of  these  regions. 

Generalized  eczema  of  the  face,  extending  to  the  neck  and  thorax, 
is  often  incited  in  adults  by  dyes  for  the  hair  and  beard,  or  is  the 
result  of  an  occupational  dermatitis.  In  children  it  is  often  recur- 
rent and  related  to  digestive  disturbances  or  the  eruption  of  teeth. 

Eczema  affecting  the  nipple  and  areola,  in  women,  is  often 
weeping,  limited,  very  obstinate  and  almost  exclusively  produced 
by  scabies  (Fig.  150),  or  pregnancy  and  lactation.  It  must  be 
carefully  differentiated  from  Paget's  disease  of  the  nipple. 

Eczema  of  the  large  folds  localized  in  the  articular,  submammary, 
subabdominal  and  intergluteal  folds,  etc;,  is  not  uncommon  in 
obese,  diabetic  or  gouty  subjects;  it  is  exudative  and  diffuse,  or 
dry  and  marginate. 

Intertrigo  eczema  of  infants  (p.  31)  represents  a  higher  degree  of 
irritative  reaction  than  simple  intertrigo  erythema. 

On  the  legs,  eczema  is  observed  very  frequently  and  in  all  its 
forms;  it  is  associated  with  varicose  veins,  traumatic  lesions,  ulcers, 
etc.,  and  leads  secondarily  to  dermatoscleroses  and  hypertrophies. 

On  the  hands,  tvrists  and  forearms  the  majority  of  eczemas  are 
caused  by  external  occupational  toxidermias;  further  on  I  shall 
discuss  dysidrosis,  which  affects  also  the  feet. 

Between  the  toes,  it  is  common  to  find  a  red  pruritic  dermatitis, 
with  exfoliation  of  large  macerated  horny  shreds.  This  form  has 
been  grouped  under  eczema,  dysidrosis  or  intertrigo  by  different 
writers;  Sabouraud  has  shown  that  it  is  usually  parasitic  and  due  to 
the  epidermophyton  inguinale. 

The  question  of  eczema  of  the  mucous  membranes  is  a  mooted 
one.  Undoubtedly,  eczema  exists  on  the  semimucosa?,  the  red 
border  of  the  lips,  glans  penis,  labia  majora  and  minora.  But  in 
the  mouth,  on  the  tongue,  in  the  nasal  fossae,  on  the  conjunctivae 
and  in  the  vagina,  the  reactions  caused  by  eczematogenic  factors 


76  ECZEMA 

are  clinically  and  histologically  different  from  those  noted  in  the 
skin. 

Course  and  Prognosis. — The  course  of  eczema  in  general  is  extremely 
variable.  Authors  recognize  an  acute  and  a  chronic  eczema,  accord- 
ing as  the  eruption  appears  abruptly  and  subsides  in  a  few  weeks,  or 
becomes  locally  established  and  recurs  during  a  period  of  months 
or  years.     This  distinction  is  arbitrary  and  useless. 

The  prognosis  of  a  given  eczema  depends  in  part  on  its  cause 
and  in  part  on  the  patient's  state  of  health,  namely  the  degree  of 
predisposition  present;  the  latter  is  often  recognized  only  a 
posteriori. 

In  a  general  way,  it  may  be  stated  that  it  is  the  nature  of  eczema 
to  advance  in  attacks  or  relays  (e/cfeyuo:,  ent;eiv,  to  boil  over  or 
effervesce).  Eczema  begins  most  frequently  but  not  always  with 
a  sudden  hyperemic  attack  with  general  malaise  in  its  course;  it  is 
the  rule  that  new  paroxysms  and  rapid  extensions  occur  at  variable 
intervals,  readily  provoked  by  external  or  internal  disturbances. 
Tins  "tendency  to  react  toward  irritants  by  an  increased  exuda- 
tion and  inflammation"  is  so  characteristic  that  Unna  included  it 
in  his  definition  of  eczema. 

During  the  intervals  of  the  attacks  there  may  be  progressive 
improvement,  or  simple  persistence,  or  progressive  aggravation;  or 
pyodermic,  lymphangitic,  etc.,  complications  may  make  their 
appearance. 

Eczema  may  constitute  a  real  infirmity,  preventing  employment 
in  a  number  of  occupations.  The  pruritus  and  desparation  caused 
by  it  have  sometimes  resulted  in  cachexia  or  even  led  to  suicide. 
Fatal  cases  for  which  eczema  has  been  held  responsible,  are  probably 
referable  to  visceral  diseases  of  which  the  eruption  was  merely  one 
manifestation  (see  Kczematosis). 

Diagnosis.  It  would  be  an  endless  task  to  point  out  all  possible 
errors.  I  snally,  moreover,  the  diagnosis  of  eczema  is  clear,  through 
the  demonstration  of  a  polymorphous  epidermodermatitis,  assum- 
ing one  or  several  of  the  above  described  clinical  aspects  and 
arranged  in  spots  or  patches  with  irregular  margins.  Vesicles 
should  not  be  credited  with  a  greater  diagnostic  value  than  the  other 
elementary  constituents,  the  process  as  a  whole  being  the  charac- 
teristic feature  of  the  disease. 

Greater  difficulties  arise  in  elucidating  the  cause  and  origin  of  the 
eczema.  The  points  to  be  determined  are  these:  Is  the  eczema 
purely  external  and,  as  it  were,  traumatic;  is  it  primary,  originating 
in  the  healthy  skin,  or  secondary  to  a  preceding  dermatosis;  what 
is  the  part  played  by  predisposition,  local  or  visceral  affections  or 
the  general  condition  of  the  patient?  The  beginner's  task  will  be 
facilitated  to  some  extent,  I  hope,  by  the  comments  which  follow 
on  some  of  the  principal  types. 


ECZEMA,  ECZEMATIZATION,  ECZEMATOSIS  77 

Treatment. — Limitation  is  imperative  in  a  field  of  such  magnitude, 
so  that  only  a  few  brief  practical  directions  will  be  presented. 

All  cases  of  eczema  should  be  treated  because  the  patient  is 
uncomfortable  and  is  threatened  with  the  danger  of  the  eruptions, 
extending  as  well  as  becoming  infected.  The  dread  of  internal 
"repercussions"  is  largely  imaginary;  although  experience  has 
shown  that  in  very  extensive  eczemas,  in  those  due  to  grave  organic 
or  nutritional  changes,  or  which  show  evidence  of  vicarious  or 
substitution  phenomena  mentioned  above,  it  is  advisable  to  apply 
only  clean  dressings  or  very  mild  soothing  lotions  and  to  avoid  all 
active  medication. 

Two  important  rules  are  as  follows :  In  every  case  of  eczema,  the 
physician  must  in  the  first  place  analyze  the  probable  causes  of  the 
eruption,  systematically  and  with  strict  attention  to  detail.  To 
begin  with,  external  irritants  are  looked  for  and  eliminated  as  far 
as  possible;  next,  preexisting  dermatoses,  with  their  marked  bear- 
ing on  the  prognosis  and  treatment  and  finally,  internal  causes, 
which  should  be  controlled  by  means  of  appropriate  measures. 

The  second,  equally  important  rule  is  that  the  treatment  of 
eczema  must  be  symptomatic  and  flexible,  rather  than  systematic 
and  predetermined.  By  this  statement  is  meant  that  the  erup- 
tion should  be  treated  according  to  its  behavior,  instead  of  blindly 
applying  one  or  other  formula  or  medication  of  "  anti-eczematous" 
repute. 

Local  Treatment. — Acute  eczematous  attacks  require  complete 
rest,  or  at  least  rest  of  the  affected  region,  with  a  prescription  of 
simple  lotions  or  spraying  with  vegetable  infusions,  or  very  mild 
antiseptic  solutions  and  generous  applications  of  neutral  powders 
which  favor  desiccation;  these  can  be  alternated  with  cooling 
creams.  Salves  and  pastes  are  all  objectionable  at  the  beginning 
of  an  acute  attack,  as  they  have  a  tendency  to  "heat"  the  skin 
and  to  macerate  the  epidermis. 

In  the  presence  of  a  crusted  or  impetiginous  eczema,  the  crusts 
should  always  be  removed  in  the  first  place  and  this  is  accomplished 
by  means  of  lotions  with  a  vegetable  or  astringent  decoction, 
such  as  very  dilute  Alibour  water  (see  Therapeutic  Notes  §  2),  or 
the  application  of  dusting  powders,  preceded  if  necessary  by  moist 
dressings  [with  Liq.  aluminis  acetatis,  1  :  water  10]  or  aseptic 
softening  poultices.  When  the  surface  is  clean  and  the  inflammation 
has  subsided,  treatment  is  begun,  while  continuing  the  use  of  lotions 
twice  daily — with  applications  of  ichthyol  pastes,  with  a  small 
addition  of  resorcin  or  yellow  oxide  of  mercury  pastes;  sometimes 
bland  powders,  glycerol  of  starch  or  watery  pastes  prove  useful. 

In  cases  of  oozing  and  itching  eczema,  painting  with  an  aqueous 
solution  of  silver  nitrate  (1  :  10  to  1  :  30)  repeated  every  two  or 
threeMays,  is*sometimes  effective. 


78  ECZEMA 

When  the  eczema  is  only  slightly  inflammatory,  without  exu- 
dation, but  squamous  or  lichenoid,  treatment  may  begin — after 
thorough  cleaning  with  vaseline  or  as  is  my  custom,  with  petroleum 
ether — with  the  series  of  pastes,  then  ointments,  made  with  tar, 
sulphur,  weak  or  strong  reducing  agents,  mercurials,  etc.,  starting 
with  the  weakest  and  passing  up  to  pure  tar,  topical  applications  of 
chrysarobin  or  pyrogallol  and  compound  plasters.  In  case  an 
excessive  reaction  follows,  milder  measures  should  be  temporarily 
resumed.  The  most  experienced  dermatologists  usually  employ 
strong  topical  applications  very  guardedly .  The  recommendation 
to  make  use  of  only  the  simplest  and  best  tried  remedies  cannot  be 
overemphasized. 

The  treatment  of  dry,  psoriatiform  and  hyperkeratotic  eczemas, 
and  of  pruriginous  eczemas,  is  the  same  as  that  of  other  dermatoses 
presenting  the  same  characters. 

Mention  must  finally  be  made  of  a  few  topical  applications  of 
more  exceptional  employment,  which  sometimes  yield  very  favor- 
able results. 

Continuous  and  direct  applications  of  caoutchouc,  or  better  of 
caoutchouc-covered  cloths,  have  enjoyed  a  considerable  vogue, 
but  they  are  often  badly  tolerated  and  it  is  difficult  to  determine 
just  when  their  employment  should  cease. 

Contrary  to  what  might  be  expected  strong  compound  ointments, 
such  as  those  [of  tar  and  sulphur  or  even  tar  and  chrysarobin]  of 
the  type  of  Baissade's  balsam  (Therapeutic  Notes,  §  7)  [or  Dreuw's 
ointment]  are  efficient  not  only  in  the  obstinate  forms,  but  also  in 
tin  case  of  acute  and  weeping  eczema.  Dind  (of  Lausanne)  has 
shown  that  crude  washed  coal  tar  can  be  employed  under  the  same 
conditions;  painted  on,  then  dusted  with  talcum  powder,  it  forms 
on  drying  a  coating  which  is  left  in  place  for  three  to  eight  days; 
this  inexpensive,  convenient  and  highly  keratoplastic  agent  has  been 
generally  adopted  and  has  rendered  excellent  service. 

The  indications  for  electrotherapy  in  the  form  of  static  baths  or 
high-frequency  currents  are  imperfectly  understood.  These  pro- 
cedures are  less  valuable  than  radiotherapy,  which  possesses  a  high 
degree  of  efficiency  in  very  pruriginous  and  lichenoid  eczemas  as 
well  as  in  the  eczemati/.ed  prurigos.  However,  it  is  resorted  to 
only  exceptionally  in  localized  and  very  obstinate  cases.  [The 
.T-rays  are  valuable  in  all  forms  of  eczema  except  the  acute,  not 
only  for  their  antipruritic  effect  but  also  for  their  action  on  the 
infilt  rations.] 

(lateral  Media/linn.-  There  is  no  specific  for  eczema,  but  in 
nearly  all  these  patients,  it  is  necessary  to  intervene  for  the  regu- 
lation of  hygienic  conditions  and  the  control  of  the  existing  tendency 
to  nutritional  or  visceral  disturbances,  if  any  such  be  disclosed. 


ARTIFICIAL  ECZEMAS  79 

The  diet,  restricted  in  quality  as  well  as  quantity,  should  be  that 
of  the  congestive  and  pruriginous  dermatoses  of  autotoxic  origin. 
A  vegetable  or  milk  diet  is  sometimes  necessary. 

Constipation  and  digestive  disturbances  must  be  carefully 
regulated.  It  is  sometimes  essential  to  train  the  patients  to  eat 
slowly  and  chew  their  food  well  (bradyphagia) ;  it  may  be  necessary 
to  insist  on  the  services  of  a  competent  dentist  for  the  repair  of 
teeth  or  the  fitting  of  dental  plates. 

General  hygiene,  a  quiet  life,  physical,  mental  and  moral  rest 
and  sojourn  in  the  open  air,  if  possible,  are  of  course  very  desirable. 

As  to  internal  medicinal  treatment,  this  varies  in  different  cases 
and  may  consist  in  the  prescription  of  alkalis,  cod-liver  oil,  calcium 
salts,  phosphates  or  phosphoric  acid,  iron  or  arsenic;  exceptionally, 
in  opotherapeutic  remedies  (such  as  thyroid,  suprarenal,  hepatic, 
ovarian,  intestinal  extracts,  etc.). 

Arsenic  medication,  formerly  considered  indispensable  in  every 
case  of  eczema,  has  greatly  fallen  in  repute  and  as  a  matter  of  fact, 
arsenic  is  more  apt  to  be  injurious  than  useful,  especially  in  the 
acute  forms.  As  a  tonic  it  may  be  advantageously  employed  in 
sluggish  eczemas  and  in  weakened  nervous  patients.  I  agree  with 
the  majority  of  dermatologists,  in  preferring  the  sodium  arsenite 
to  the  cacodylates,  methyl  arsenites  or  analogous  preparations. 

It  is  difficult  to  state  in  a  few  words  what  mineral  waters  are 
suitable  for  eczematous  patients.  In  a  general  way,  the  lymphatic 
group  may  be  referred  to  sulphur  springs;  the  gouty  to  alkaline 
and  silicate  springs;  nervous  irritable  persons  are  benefited  by 
waters  charged  with  calcium  sulphates;  nervous  patients  suffering 
from  auto-intoxication  do  well  on  so-called  neutral  and  sedative 
waters;  long-standing  cases  of  the  dry  and  lichenoid  type  may 
employ  arsenical  waters. 

Some  of  the  most  frequent  clinical  types  of  eczema  are  entitled  to 
a  special  discussion: 

ARTIFICIAL  ECZEMAS. 

Their  special  features  depend  upon  their  cause,  localization  and 
evolution. 

The  irritants  most  apt  to  incite  an  eczematous  reaction  and  the 
occupations  which  most  often  lead  to  its  occurrence  are  discussed 
in  the  chapter  on  the  artificial  dermatitides  (pp.  463,  467). 

The  artificial  eczemas  naturally  develop  first  of  all  in  the  regions 
directly  exposed;  on  the  hands,  especially  in  the  interdigital  folds, 
on  the  wrists  and  forearms,  in  cases  of  occupational  eczema  (see 
Figs.  8  and  144) ;  on  the  face  and  neck,  in  dermatitis  due  to  dyes,  etc. 


SO  ECZEMA 

They  have  a  tendency  to  spread  by  peripheral  extension,  but 
may  also  advance  in  leaps,  reaching, for  instance,  the  face,  the  neck, 
the  thighs  or  the  genital  regions. 

Several  explanations  of  these  transferences  have  been  sug- 
gested. The  injurious  substance  was  assumed  to  have  been  trans- 
ported, for  example,  by  the  patient's  fingers,  which  is  possible  in 
certain  cases;  or  the  toxic  agent  was  believed  to  have  undergone 
absorption,  manifesting  it^  effect  from  within  outward,  in  predis- 
posed regions;  again,  the  eruption  at  a  distance  was  interpreted  as 
the  result  of  a  reflex  action,  although  it  is  hardly  likely  for  a  true 
inflammation  to  be  the  result  of  a  purely  nervous  pathogenesis. 
The  most  plausible  explanation,  in  my  opinion,  is  that  which 
regards  the  [reflex]  diffusion  of  the  pruritus  as  the  predisposing 
cause  and  the  scratching  or  the  transportation  of  the  microbic 
invaders  of  the  first  eczematous  focus,  as  the  determining  cause. 

The  artificial  eczemas  are  often  distinctly  vesicular  from  the 
start;  or  they  may  be  erythemato-edematous  or  even  erysipelatoid, 
quite  at  the  beginning,  becoming  vesicular  secondarily.  They  are 
very  commonly  infected  by  pyococci  and  become  impetiginous  in 
places,  while  elsewhere  they  become  keratotic,  present  fissures  and 
cracks,  become  covered  with  crusts  and  assume  a  nummular  or 
lichenoid  appearance.  Extraordinarily  polymorphous  but  never- 
theless characteristic  appearances  are  the  result,  such  as  those  to 
which  special  names  like  grocers'  itch,  bricklayers'  and  cement- 
workers'  itch,  etc.,  have  been  given. 

Sometimes,  sublata  causa,  a  cure  follows  with  the  greatest 
rapidity  and  almost  without  treatment;  cases  of  this  kind  are 
described  as  traumatic  eczematiform  dermatitides.  However,  all 
intermediary  degrees  occur  between  this  contingency  and  that  of 
prolonged  persistence,  with  recrudescence  without  apparent  cause 
and  with  invasion  of  and  establishment  in  remote  areas,  represent- 
ing a  true  eczema,  originating  from  a  focus  of  local  irritation. 

Even  when  a  more  <>r  less  rapid  cure  is  obtained,  the  patient 
remains  predisposed  to  recurrences  under  the  influence  of  the  same 
cause  in-  analogous  causes  through  the  effect  of  a  sensitization 
which  has  been  compared  with  anaphylaxis;  and  a  change  of 
occupation  may  become  imperative. 

INFANTILE    ECZEMAS. 

In  lii tic  children,  especially  between  the  second  to  the  eighth 
month,  eczemas  of  rather  peculiar  etiology,  topography  and  evolu- 
tion arc  observed  with  great  frequency  'in  5  or  10  per  cent,  of 
children  in  Paris).  These  children  are  apt  to  have  eczematous, 
neuropathic,    intemperate    or    overworked    parents.    Their   diet, 


SECONDARY  ECZEMATIZATION  81 

whether  they  are  breast-fed  or  raised  by  hand,  in  the  presence  or 
absence  of  evident  digestive  disturbances,  may  be  injurious  by  its 
quality,  its  too  frequent  repetition  and  especially,  as  has  been 
shown  by  Marfan,  through  an  oversupply  of  food.  It  must  be 
watched  and  regulated  according  to  the  requirements  in  a  given 
case.  Weaning,  when  carefully  managed,  is  not  particularly 
dangerous  in  infantile  eczemas  and  may  on  the  contrary  lead  to  a 
cure.  The  part  played  by  the  eruption  of  the  teeth,  although  it 
has  been  exaggerated,  is  evident  in  many  cases;  it  acts  by  the  con- 
gestions, nervous  condition  and  digestive  disturbances  with  which 
it  is  associated.  Various  local  causes,  bad  hygiene  of  the  skin,  an 
excessive  use  of  soap,  coryza,  impetigo,  vaccination,  etc.,  may  all 
serve  as  determining  factors. 

Infantile  eczema  affects  preferably  the  face,  especially  the  cheeks, 
the  forehead  and  the  lips,  while  the  nose  and  chin  often  escape. 
Sometimes  it  begins  on  the  healthy  skin  in  a  distinctly  vesicular 
form,  followed  by  oozing;  in  other  cases  it  originates  in  the  sebace- 
ous ducts  of  the  scalp  and  forehead,  where  it  is  known  as  "milk- 
crust,"  forming  a  continuous  series  from  pityriasis  simplex  to  dry, 
impetiginous,  or  even  exudative  and  crusted  eczema;  sometimes 
again,  although  the  two  preceding  forms  are  likewise,  as  a  rule, 
accompanied  by  erosions,  the  eruption  is  obviously  secondary  to  a 
primary  localized  pruritus  and  to  the  scratching  provoked  by  it. 

This  eczema  may  remain  localized,  or  it  may  extend  as  far  as  the 
buttocks,  the  limbs  and  the  trunk.  The  general  condition  often 
remains  excellent  and  the  eruption  usually  stops  and  disappears 
about  the  middle  or  end  of  the  second  year. 

Its  etiology,  localization  and  course  differentiate  true  infantile 
eczema  from  eczematiform  dermatitis,  usually  starting  from  the 
buttocks,  which  has  been  referred  to  above;  the  latter  represents 
merely  an  advanced  degree  of  intertrigo-erythema  and  is  entitled 
to  the  designation  of  intertrigo-eczema. 

SECONDARY   ECZEMATIZATION. 

Eczematization  which  develops  on  the  soil  of  other  dermatoses 
and  is  provoked  by  the  same,  seems  to  be  the  cause  of  much  con- 
fusion in  the  classical  picture  of  eczema.  Familiarity  with  this 
mode  of  origin  of  eczema  which  depends  on  the  so-called  pre- 
eczematous  dermatoses  is  of  the  greatest  practical  importance  for 
the  clinician  as  in  a  large  number  of  cases  it  enables  the  clinician 
to  make  a  correct  diagnosis  and  prognosis  and  to  institute  pre- 
ventive treatment.  Moreover,  on  the  assumption  that  eczema  is 
merely  a  mode  of  cutaneous  reaction,  the  theoretical  explanation 
of  these  facts  meets  with  no  insurmountable  difficulties. 


82  ECZEMA 

Eczema  and  Impetigo.  The  relations  of  impetigo  to  eczema  are 
complex  and  have  given  rise  to  various  interpretations.  Clinical 
findings  are  rendered  intelligible  on  the  basis  of  the  following 
considerations : 

Impetigo  or  superficial  pyoeoccic  infection  of  the  epidermis  is 
very  frequently  grafted  on  an  existing  eczema,  whatever  its  origin, 
external  and  artificial  or  internal  and  constitutional.  The  result  is 
a  modification  of  the  clinical  aspect  of  the  eczema,  the  secretion 
becoming  purulent  and  the  crusts  melicerous  and  coarse,  consti- 
tuting impetiginized  eczema.  The  neighboring  lesions  or  auto- 
inoculations,  the  result  of  scratching,  may  be  the  lesions  of  eczema 
or  the  pustules  of  impetigo,  or  a  mixture  of  the  two. 

Conversely,  impetigo  may  give  rise  to  eczema,  in  this  sense  that 
the  pyoeoccic  agents  of  impetigo  under  certain  conditions  (prob- 
ably when  they  possess  a  high  degree  of  virulence)  and  in  certain 
regions,  are  capable  of  giving  rise  to  epidermodermatitis  of  the 
eczematous  type  like  other  irritants.  This  microbic  eczema, 
which  might  be  called  impetiginous  eczema,  unlike  impetiginized 
eczema,  lacks  constant  characteristics  and  I  believe  it  may  assume 
the  aspect  of  a  vesicular  or  oozing,  crusted  or  squamous  eczema,  or 
even  that  of  dry  eczema.  The  investigations  of  Sabouraud  have 
even  led  to  the  conclusion  that  pityriasis  simplex  may  be  regarded 
as  a  "dry  impetigo." 

This  second  proposition  will  hardly  be  admitted  offhand ;  although 
it  is  based  upon  a  number  of  histological  and  bacteriological  exami- 
nations carried  out  in  my  laboratory  with  careful  analysis  of  clinical 
cases  and  is,  I  believe,  in  harmony  with  the  existing  facts. 

Eczema  and  Kerosis.  The  pathological  conditions  of  the  epidermis 
known  as  pityriasis  and  seborrhea,  grouped  by  me  under  the  heading 
kerosis  (p.  196),  create  a  territory  peculiarly  predisposed  to  eczema- 
tization.  Most  commonly,  an  eczematide  or  dry  eczema  develops 
under  these  conditions,  but  this  dry  eczema  has  a  marked  tendency 
to  react  in  the  form  of  exudation  and  extensive  inflammation  under 
the  influence  of  scratching,  injudicious  treatment,  or  other  local 
and  general  causes;  constituting  the  eczematized  seborrheic!  of  some 
authors. 

Vesicular,  oozing,  crusted,  impetiginous  eczema  may  likewise 
become  established  from  the  start  in  cases  of  kerosis.  The  sites 
of  predilection  of  kerosis,  primarily  the  hairy  scalp,  the  face  and  the 
large  articular  folds,  are  naturally  also  the  usual  starting-points  of 
these  eczemas. 

The  kerotic  origin  of  eczema  is  so  common  that  according  to 
I'nna,  the  great  majority  of  eczemas  would  be  suppressed  by 
treating  and  curing  seborrheal  eczema  in  its  early  stages. 


ECZEMATOSIS  83 

Eczema  and  Prurigo. — Pruritus  and  prurigo,  diffuse  or  localized, 
of  variable  origin,  are  conditions  very  apt  to  become  eczematized 
and  the  starting-point  of  more  or  less  extensive  and  generalized 
eczemas.  Scratching,  through  its  mechanical  action  and  the 
resulting  microbic  inoculation,  constitutes  the  pathogenic  factor 
in  this  complication,  which  is  met  with  in  the  urticarias  and  in 
scabies.  However,  not  all  scratched  prurigos  become  eczematized, 
but  have  rather  a  tendency  to  lichenize,  indicating  that  a  certain 
degree  of  local  or  general  predisposition  is  necessary. 

It  must  not  be  overlooked,  on  the  other  hand,  that  primary 
eczema  is  itself  pruriginous  and  becomes  lichenized  under  certain 
conditions  of  persistence,  localization  and  soil.  The  relations  of 
eczema  with  the  pruriginous  dermatitides  are  accordingly  complex, 
the  particular  cases  requiring  careful  analysis. 

Aside  from  these  three  conditions  in  which  eczematization  is 
extremely  common,  a  long  list  of  dermatoses  should  be  men- 
tioned which,  although  less  frequently,  may  become  complicated 
by  eczema. 

Mycosis  Fungoides. — Mycosis  fungoides  includes  patches  of  lichen- 
oid eczema  among  its  common  initial  symptoms.  The  exfoliating 
erythrodermas  are  often  eczematized,  especially  in  the  folds.  The 
ichthyoses  and  hyperkeratoses  are  likewise  subject  to  eczematiza- 
tion. Hyperidrosis  and  intertrigo-erythema  mustalso  be  mentioned 
among  the  pre-eczematous  dermatoses. 

ECZEMATOSIS. 

Under  this  name  I  designate  the  chronic,  constitutional  or 
dyscratic  disease,  in  which  the  eczema  eruption  is  the  principal 
manifestation  and  which  is  generally  designated  under  the  name  of 
true  eczema  or  eczema  disease. 

Eczematosis  is  met  with  at  all  ages.  Certain  eczemas  of  new- 
born infants  belong  under  this  heading;  in  the  course  of  childhood, 
adolescence  and  youth,  it  seems  to  be  an  attribute  of  lymphatic, 
anemic  or  scrofulous  individuals;  at  the  age  of  maturity,  it  affects 
the  overworked,  inebriate  and  intemperate,  the  wealthy  class  being 
more  susceptible  than  hospital  and  dispensary  patients.  It  is 
especially  common  in  arteriosclerotic  and  senile  individuals  where 
it  becomes  a  very  distressing  and  often  almost  incurable  infirmity. 
I  have  often  been  put  on  the  track  of  a  latent  visceral  cancer  or  a 
partial  retention  of  urine,  pyelonephritis,  etc.,  by  incessant  rebel- 
lious attacks  of  eczema  in  an  aged  man. 

In  a  general  way,  the  etiology  of  eczematosis  is  characterized 
by  the  fact  that  the  local  or  external  causes  play  a  rather  un- 
important part,   whereas  the   so-called   internal  causes  together 


84  ECZEMA 

with  ;i  predisposition  of  organic  or  humoral  origin  occupy  the 
first  rank.  In  the  presence  of  eczematosis,  visceral  lesions  and 
chronic  intoxications  are  often  demonstrable  to  such  a  degree 
that  it  is  difficult  to  determine  the  precise  cause.  In  other  cases, 
the  behavior  suggests  a  sensitization  of  the  patient  through  mul- 
tiple or  polyvalent  antigens,  rendering  him  susceptible  to  slight  or 
even  inappreciable  causes. 

Almost  invariably,  however,  the  onset  of  the  eczematosis  can 
be  referred  to  a  cutaneous  traumatism,  an  accidental  local  irrita- 
tion, repeated  scratching  induced  by  anal  or  genital  pruritus, 
inflamed  varicose  veins,  etc.  Or  it  may  take  its  origin  in  a  pro- 
tracted pityriasis  of  the  scalp,  or  in  an  old  patch  of  dry  eczema. 
Finally,  it  is  seen  to  occur,  as  if  through  the  effect  of  a  "metas- 
tasis" or  substitution,  at  the  time  of  spontaneous  or  artificial 
suppression  of  asthma,  bronchial  catarrh,  enteritis,  neuralgia  or 
rheumatic  pains. 

Finally,  the  most  trifling  causes,  the  mildest  applications,  wash- 
ing with  soap,  fatty  substances  and  even  water  may  provoke  attacks. 
The  skin  of  persons  having  constitutional  eczema  seems  to  have 
become  less  capable  of  adjusting  itself  to  external  conditions  and 
they  are  attacked  by  paroxysms  on  occasions  such  as  a  change  of 
temperature,  season,  climate,  or  humidity  of  the  air,  on  exposure 
to  wind,  etc.;  briefly,  any  condition  which  modifies  the  state  of  the 
cutaneous  circulation  and  secretion. 

The  clinical  picture  of  eczematosis  need  not  detain  us.  It  will 
suffice  to  state  that  the  eruption  may  assume  any  form  and  degree, 
and  affect  any  region,  as  discussed  under  eczema  in  general.  The 
pruritus  is  variable  in  degree,  often  intolerable,  paroxysmal  and 
especially  nocturnal,  contributing  on  the  one  hand  to  the  main- 
tenance of  the  lesions  through  the  scratching  caused  by  it  and  on 
the  other  to  the  depression  of  the  nervous  system  and  the  morale 
of  the  patient. 

Notwithstanding  intelligent  and  scrupulous  treatment,  a  cure 
cannot  always  be  obtained,  or  it  is  only  temporary  and  followed  by 
recurrences.  It  is  very  common  for  these  recurrences  or  renewed 
attacks  to  start  from  an  imperfectly  extinct  focus,  a  focus  of  microbic 
growth  according  to  the  adherents  of  the  parasitic  theory  of  all 
eczemas.  The  disease  lasts  years  and  sometimes  till  death,  wrhich 
may  occur  in  consequence  of  the  organic  lesions  back  of  the  erup- 
tion, such  as  Bright's  disease,  arteriosclerosis,  chronic  bronchitis, 
cancer,  diabetes,  etc. 

It  frequently  happens  that  the  eczema  disappears  at  the  moment 
where  the  terminal  complications  supervene,  and  quite  naturally 
so,  because  the  exhausted  organism  is  no  longer  capable  of  respond- 
ing with  a  cutaneous  reaction.     The  fact  is  generally  interpreted 


DYSIDROSIS 


85 


by  the  laity  and  by  a  number  of  physicians  as  indicating  a  reper- 
cussion, a  "striking  in"  of  the  eruption,  the  effect  being  mistaken 
for  the  cause. 

DYSIDROSIS. 

Under  this  name,  proposed  by  Tilbury  Fox,  is  designated  an 
affection  (named  cheiropompholyx  by  Hutchinson)  which  is  gen- 
erally regarded  as  a  special  disease,  but  which  to  me  seems  to  be 
simply  a  clinical  form  of  eczema,  characterized  by  certain  shades 
in  the  behavior  of  the  eruption,  by  its  seat  and  by  its  course. 


Fig.  12. — Occupational  eczema  of  the  dysidrotic  types  in  a  hair-dresser  aged 
twenty-eight  years. 

Dysidrosis  is  seen  especially  in  the  spring,  from  March  to  June, 
sometimes  in  the  fall.  It  recurs  in  a  given  case  frequently  at  the 
same  time  of  the  year.  Patients  suffering  from  it  are  adults, 
rarely  children;  they  present  some  of  the  disturbances  referable  to 
arthritism;  frequently  they  are  dyspeptic,  nervous  or  overworked 
and  perspire  very  readily.  The  attack  may  be  caused  by  violent 
exercise  or  by  an  emotional  disturbance. 

The  eruption  begins  symmetrically  on  the  hands  or  feet,  or  all 
four  extremities  at  once;  it  consists  of  small  or  medium-sized  vesicles. 


86  ECZEMA 

deeply  set  in  the  thick  epidermis,  appearing  without  redness  but 
with  sensations  of  pruritus,  heat,  or  pain  on  pressure,  sometimes 
very  distressing. 

It  assumes  its  most  typical  aspect  on  the  lateral  surfaces  of  the 
fingers,  where  the  skin  is  white  or  pinkish  and  studded  with  vesicles 
as  if  with  grains  of  boiled  sago.  The  vesicles  may  attain  the  size 
of  a  lentil  and  become  confluent  in  bullae  of  the  dimensions  of  an 
almond  or  larger,  especially  on  the  palms  and  the  soles.  A  clear, 
very  stringy,  neutral  or  alkaline  fluid  escapes  on  puncture;  the 
fluid  is  sometimes  turbid  and  on  the  soles  is  usually  purulent. 
The  vesicles  of  dysidrosis  have  not  much  tendency  to  open  spon- 
taneously and  usually  dry  up  in  a  few  days,  the  epidermis  becomes 
exfoliated  and  is  shed,  disclosing  a  smooth  pinkish  surface  which 
does  not  ooze.  The  course  of  an  attack  lasts  from  five  to  twenty 
days. 

The  eruption  may  become  infected,  impetiginous,  especially  on 
the  feet  and  give  rise  to  fissures,  lymphangitis,  etc.  It  is  usually 
symmetrical.  It  may  invade  the  forearms,  the  neck,  the  face,  a 
considerable  portion  of  the  trunk,  or  even  become  generalized  when 
it  represents  what  has  been  called  a  dysidrotic  eczema. 

The  pathological  anatomy  of  the  vesicles  of  dysidrosis  shows 
round  or  oval  cavities,  hollowed  out  at  different  levels  of  the 
rete.  Originating  in  the  process  of  spongiosis,  they  are  filled  with 
a  moderate  leukocytic  fluid  which  causes  a  pressure  condensation 
of  the  neighboring  epithelial  cells.  They  have  no  relation  to  the 
sweat  channels.  The  special  bacillus  reported  by  I  una  has  not 
been  found  by  others.  Briefly,  there  are  no  anatomical  reasons  for 
considering  dysidrosis  as  a  special  dermatosis. 

Clinical  arguments  are  of  no  greater  value.  Artificial  eczema, 
when  it  affects  the  same  localizations  or  any  region  with  a  thick 
horny  layer,  presents  an  identical  aspect.  Generalized  dysidrotic 
eczema  differs  in  no  way  from  an  ordinary  eczema.  Nothing 
definite  is  known  as  to  the  causes  of  seasonal  recurrences,  which 
are,  moreover,  inconstant  or  very  irregular.  Having  excluded,  in 
the  case  of  the  hands,  artificial  eczemas  caused  by  turpentine, 
iodoform,  poisonous  plants  or  other  irritants;  at  the  feet,  conditions 
like  epidermophytosis  of  the  toes  and  ordinary  eczema,  no  cases 
are  left  entitled  to  the  label  of  dysidrosis.  It  is  therefore  my 
belief,  shared  by  .Jadassohn,  that  this  affection  is  not  truly  auton- 
omous. According  to  Kaufmann-Wolf  (1914),  about  one-third  of 
the  cases  somewhat  generally  labelled  as  dysidrosis  are  of  a  tricho- 
phytic  or  epidermophytic  character. 

There  is  a  desquamation  of  the  hands  and  feet,  a  recurrent  and 
often  seasonal  affection,  which  is  referred  to  dysidrosis  in  which  the 
epidermis  dries  and  becomes  detached  at  scattered  points  or  over 


DISSEMINATED  ECZEMA   OR  MILIARY  IMPETIGO 


87 


polycylic  surfaces.  In  my  opinion  this  is  connected  with  general 
nutritional  disturbances,  auto-intoxications,  or  latent  infections,  such 
as  chronic  appendicitis,  dyspepsias,  pyelonephritis,  etc. 

It  is  almost  superfluous  to  state  that  dysidrosis  has  nothing  in 
common  with  sudamina,  or  intracorneal  vesicles  observed  on  the 
trunk  and  limbs  in  cases  of  fever  with  profuse  sweating;  nor  with 
hydrocystoma  or  intradermic  cysts,  due  to  dilatation  of  the  sweat 
channels. 

ACUTE  DISSEMINATED  ECZEMA  OR  MILIARY  IMPETIGO. 

Under  this  title  I  describe  a  clinical  type  comprising  the  erup- 
tions which  have  been  named  acute  disseminated  morococcal 
eczema  (Unna);  miliaria  rubra  or  alba;  sudoral  eruptions  (prickly 
heat,  lichen  tropicus,  etc.). 


Fig.  13. — Miliary  impetigo  of  the  back,  following  profuse  perspiration. 


It  is  possible  that  this  type  corresponds  to  several  distinct  patho- 
logical entities;  at  the  present  time  they  are  inseparable. 

The  symptomatology  is  as  follows:  In  a  young  adult  usually 
of  the  male  sex,  one  notes  the  appearance,  after  profuse  sweats 
caused  by  a  rise  of  temperature,  a  steam-bath,  hard  work,  or 
after  cutaneous   irritation  such  as  a  sulphur  bath,  of  an  acute 


88  ECZEMA 

eruption  of  red  spots,  the  size  of  a  pin-head,  having  for  their  center  a 
minute  vesicle  with  turbid  contents.  There  is  no  induration  of 
the  lesions,  no  papular  elevation  as  in  eczema  of  the  papulovesicular 
type  of  Brocq;  nor  is  the  eruption  follicular.  It  occurs  especially 
on  the  trunk  or  the  first  segments  of  the  limbs.  The  pruritus  is 
variable,  sometimes  quitesevere. 

Often,  but  not  always,  the  previous  existence  of  impetigo,  impe- 
tiginized  or  common  eczema,  furuncles  or  a  suppurating  wound, 
can  be  demonstrated  in  these  patients. 

The  course  is  rapid  and  under  proper  care  the  skin  not  infre- 
quently clears  up  in  three  or  four  days.  Successive  attacks  may 
also  occur.  Sometimes,  especially  in  irritated  or  scratched  regions 
one  or  more  foci  of  ordinary  or  impetiginous  eczema  form. 

Histology  shows,  at  a  point  of  congestive  and  edematous  derma- 
titis, a  minute  blister  of  the  impetigo  type  (that  is,  produced  by 
cleavage),  or  of  the  eczema  type  (that  is,  through  spongiosis),  wTith 
serous  contents  more  or  less  rich  in  polynuclears;  sometimes  there 
is  a  combination  or  a  succession  of  these  two  processes.  It  is  com- 
mon, but  not  constant,  for  the  little  vesicle  to  have  a  swTeat  channel 
for  its  center,  although  it  does  not  originate  through  dilatation  of 
one  of  the  canals.     A  follicular  location  is  unusual. 

Investigations  carried  out  in  my  laboratory  go  to  show  that 
various  staphylococci  may  be  found  in  the  lesions,  in  different  cases, 
especially  citreus  and  albus;  these  are  the  morococci  of  Unna. 

In  my  opinion  this  is  a  microbic  auto-inoculation,  scattered  in 
consequence  of  the  maceration  of  the  epidermis  by  the  sweat. 

It  win ild  be  logical  to  classify  this  eruption  with  the  impetigos 
on  account  of  its  pathogenesis  and  evolution,  rather  than  with 
eczema,  since  its  lesions  are  not  agglomerated  and  have  no  tendency 
to  oozing.  I  am  considering  it  here  only  because  objectively  it 
resembles  eczema  and  has  no  resemblance  at  all  to  ordinary  impetigo. 

Very  simple  treatment  w7ith  non-irritating  washes  and  applications 
of  bland  powders  or  watery  pastes,  suffices  for  a  cure.  Preexisting 
suppurations  should  be  treated  if  necessary,  and  some  rest  should 
be  recommended. 


CHAPTER  V. 
ERYTHEMATO-SQUAMOUS  DERMATOSES. 

There  exists  a  group  of  dermatoses  characterized  by  red  and 
scaling  spots.  It  might  be  supposed  that  the  eruptive  lesions 
designated  by  these  few  words  are  very  common,  but  this  is  not  the 
case  provided  the  terms  be  used  in  a  strict  sense.  The  word  "spots" 
is  here  employed  in  its  widest  application;  by  their  large  dimensions, 
the  spots  under  consideration  may  be  entitled  to  the  name  of  patches 
or  plaques.  The  redness  must  be  of  a  congestive,  erythematous 
character,  disappearing  momentarily  under  pressure  of  the  finger; 
it  is  circumscribed,  limited  to  the  spots  and  not  diffuse.  Desquama- 
tion is  present  from  the  start  and  in  all  cases  it  is  of  the  powdery 
furfuraceous  type  though  sometimes  micaceous  or  scaly  and  prac- 
tically always  connected  with  the  modified  keratinization  known  as 
parakeratosis. 

This  definition  accordingly  excludes:  (1)  Red  spots  which  are  not 
squamous  or  only  become  so  later  on;  these  belong  to  the  erythemas 
(I) ;  (2)  Squamous  spots  which  are  not  red  and  which  belong  to  the 
keratoses  (XI) ;  (3)  Generalized  or  very  extensive  reddening,  which 
is  known  as  erythroderma  (VI). 

When  the  spots  are  small  and  manifestly  surround  the  hair  follicles, 
I  consider  them  as  folliculoses  (XIX). 

Erythemato-squamous  spots  may  be  secondary  to  a  great  variety 
of  eruptions,  of  erythematous,  eczematous,  vesicular,  pustular  or 
bullous  type;  representing,  not  a  genuine  eruption,  but  old  and 
deformed  lesions  about  to  become  macula?  (XVI,  p.  322). 

I  shall  here  discuss  only  syndromes  of  primary  erythemato-squam- 
ous eruptions  which  originate  and  persist  under  this  form. 

Such  are:  (1)  The  eczematides;  (2)  pityriasis  rosea;  (3)  psoriasis 
and  (4)  the  parapsoriases;  to  which  will  be  added  a  few  words  or 
(5)  the  psoriatiform  syphilides,  and  on  (6)  certain  epidermomycoses. 

This  does  not,  however,  exhaust  the  list  of  cutaneous  affections 
capable  of  presenting  the  same  eruptive  type.  As  a  matter  of  fact, 
it  may  be  met  with,  under  special  features,  in  certain  varieties  of 
lupus  erythematodes  (XXVII,  p.  568)  and  the  tuberculides  which 
approach  it  more  or  less  closely;  in  leprosy  (XXVII,  p.  578)  and  in 
mycosis  fungoides  (XXIX,  p.  657). 


'."  i  ERYTHEMATO-SQUAMOUS  DERMATOSES 

The  reader  is  referred  to  the  corresponding  chapters  on  these 
diseases,  which  are  omitted  here  in  the  interest  of  a  more  complete 
description.  For  analogous  reasons,  the  red  and  squamous  spots 
of  the  palmar  and  plantar  regions,  as  well  as  those  of  the  mucous 
membranes,  are  discussed  in  the  chapter  on  the  Keratoses  (XI). 

ECZEMATIDES. 

I  propose  the  name  of  eczematides,  to  designate  the  group  of 
erythemato-squamous  dermatoses  in  spots  or  circumscribed  patches, 
commonly  called  seborrheal  eczemas,  seborrhoids,  or  dry  eczemas. 

Different  authors  consider  them  as  related  to  pityriasis  and 
psoriasis  or  as  a  type  by  themselves. 

The  relations  of  these  eruptions  with  seborrhea  are  inconstant. 
I  believe  them  to  be  closely  akin  to  eczema,  for  two  reasons:  because 
of  the  clinical  observation  of  imperceptible  transitions  and  because 
histologically  the  lesions  are  practically  identical.  However,  they 
cannot  be  simply  incorporated  with  eczema,  for  the  reason  that  the 
lesions  differ  clinically  from  the  latter  by  the  four  following  proper- 
ties: their  usual  dryness;  the  sharpness  of  their  rounded  or  poly  cyclic 
outlines;  their  very  prolonged  persistence  under  the  same  aspect; 
their  very  ready  curability  under  the  influence  of  local  treatment. 

The  name  1  have  selected  seems  to  me  convenient,  indicating  the 
affinities  and  suggesting  the  special  characteristics  of  these  eruptions. 

Synonyms  and  Historical  Data. — In  view  of  their  great  frequency, 
the  eczematides  have  always  attracted  the  attention  of  dermatol- 
ogists.  They  have  borne  very  many  names,  which  prove  the 
difficulties  encountered  in  their  classification:  lichen  circumscriptum 
(Willan  and  Bateman);  lichen  gyratus  (Cazenave  and  Biett);  lichen 
annulatus  serpiginosus  (E.  Wilson);  eczema  acneiforme  and  pityriasis 
circinata  I  Bazin);  it  is  the  dry,  circinate  eczema  figuration  or  "flannel 
eczema"  of  the  dermatologist  of  the  Saint  Louis  Hospital,  the 
eczema  marginatum  of  Pick,  Kobner,  Ilebra  and  Hardy,  the  seborrhea 
corporis  of  Duhring,  the  eczema  seborrhoeicum  of  Unna.  There  has 
always  been  a  tendency  to  consider  these  eruptions  as  of  parasitic 
origin. 

The  name  seborrheal  eczema  has  proved  decidedly  the  most 
popular.  Inna,  as  far  back  as  1887,  not  questioning  the  eczematous 
character  of  the  dermatosis  thus  named  by  him,  pointed  out  that 
the  eruption  preferably  attacks  the  seats  of  election  of  seborrhea 
and  that,  moreover,  it ->  scales  or  crusts  have  a  fatty  consistence. 
The  name  coined  by  him  Mas  based  on  these  observations.  Being 
struck,  furthermore,  by  the  fact  that  all  intermediary  degrees  are 
encountered  between  these  eczemas  with  fatty  scales  and  pityriasis 
on  one  hand  and  certain  forms  of  psoriasis  on  the  other,  he  was  led 


ECZEMATIDES 


91 


to  extend  immoderately  the  limits  of  seborrheal  eczema.  His 
teachings,  originally  received  with  high  favor,  did  not  fail  to  arouse 
severe  criticism.  On  the  one  hand,  the  eczematous  nature  of  the 
process  was  contested,  hence  the  name  of  seborrhoids,  proposed  by 
Brocq  and  Audry;  on  the  other  hand,  it  was  demonstrated  that  this 
process  is  not  invariably  seborrheal. 

The  group  has  now  been  arbitrarily  broken  up:  various  con- 
stituents are  classified  as  steatoid  pityriasis,  by  Sabouraud,  as 
medio-thoracic  dermatosis  and  psoriatiform  keratosis,  by  Brocq,  etc. 


Fig.   14. — Figured  eczematide  of  the  interscapular  region  of  the  back. 


In  my  own  opinion,  the  prevailing  confusion  on  this  subject  would 
practically  disappear  by  keeping  in  mind:  (1)  that  there  exists  a 
cutaneous  dystrophy  which  I  have  named  kerosis  (XI),  ordinarily 
manifesting  itself  through  pityriasis  and  seborrhea;  (2)  that  this 
kerotic  soil  is  a  seat  of  predilection  for  the  development  of  various 
inflammatory   complications   which  very  frequently   assume   the 


Ml' 


ERYTHEMATO-SQUAMOUS  DERMATOSES 


clinical  form  of  eczematides  or  sometimes  that  of  moist  eczema, 
or  still  other  forms,  such  as  rosacea,  acne,  etc. 

The  eczematides  are  then-fore  interpreted  by  me  as  dry  and  cir- 
cumscribed eczemas,  which  on  account  of  these  characteristics 
deserve  to  be  distinguished  from  the  ordinary  eczemas,  and  which 
in  the  vast  majority  of  eases,  though  not  invariably,  develop  on  a 
kerotic  soil. 


Fig.   l  ■">.     Figured  eczematide  of  the  forehead  (corona  seborrhoica,  qoI  to  be 

confused  with  the  "corona  veneris"). 


Symptoms.  The  eczematides  are  practically  always  preceded 
and  accompanied  in  their  vicinity  by  manifestations  of  kerosis. 
In  the  mildest  degree,  it  is  very  difficult  to  discern  if  the  complica- 
tion exists  or  not;  a  judgment  must  he  based  on  the  presence  of 
circumscribed  and  scaly  redness. 

Well-developed  eczematides  possess  typical  characteristics,  differ- 
ing slightly  according  to  their  seat  and  variety. 

1 .  Figured  Eczematides.  This  first  group  corresponds  to  "eczema 
llanellaire,"  the  petaloid  and  circumscribed  type  of  Unna,  the 
steatoid  pityriasis  of  Sabouraud,  the  medio-thoracic  figured  derma- 
tosis of  Brocq,  the  seborrhea  corporis  of  Duhring. 


ECZEMATIDES  93 

The  eruption  at  the  onset  almost  invariably  occupies  the  pre- 
sternal  and  interscapular  regions;  from  here  it  extends  to  a  greater 
or  less  distance  from  the  median  line  according  to  its  severity  and 
duration.  It  is  seen  also  on  the  scalp,  whence  it  extends  to  the  fore- 
head, temples  and  postauricular  region. 

The  lesions  begin  as  pinkish  punctiform  spots  covered  with  a 
greasy  scale.  Next,  they  spread  as  nummular,  petaloid  or  poly- 
cyclic,  coalescent,  more  or  less  numerous  spots,  having  the  following 
characteristics:  sharply  marked  outlines;  pinkish  or  bright  red, 
often  slightly  elevated  papular  borders,  covered  with  yellowish 
scales  and  crusts  which  are  of  a  fatty  consistence  when  squeezed 
between  two  fingers ;  a  flattened  surface,  on  a  level  with  the  normal 
skin,  of  a  yellowish  pink  color,  often  covered  with  scales  less  thick 
than  on  the  margins;  no  apparent  vesicles  and  no  infiltration  of  the 
base.  Scraping  the  margin  with  the  finger-nail  or  with  a  curette 
causes  the  appearance,  according  to  Brocq,  of  a  minute  purpura, 
droplets  of  serous  fluid  and,  finally,  small  punctiform  hemorrhages. 

While  extending,  some  of  the  spots  heal  in  the  center  or  in  a  portion 
of  their  periphery.  In  the  zone  of  invasion,  the  follicular  orifices  are 
often  attacked  first,  which  explains  the  name  of  acneiform  eczema, 
proposed  by  Bazin.  Pruritus  is  moderate  and  intermittent  or  it 
may  be  altogether  absent. 

The  duration  of  the  eruption  is  indefinite  and  patients  are  not 
uncommonly  met  with  who  have  suffered  from  it  for  twelve  or 
fifteen  years.  Appropriate  treatment  causes  it  to  disappear  in  ten 
to  fifteen  days. 

2.  Pityriasis orm  Eczematides.- — The  characteristic  features  of 
these  cases  are  less  definite.  The  lesions  consist  of  pinkish  or 
yellowish  pink  spots,  with  a  surface  covered  with  fine  scales,  dry  or 
slightly  oily  in  the  kerotic  areas  and  rather  distinctly  circumscribed. 
Their  form  is  round,  oval,  or  irregular;  their  dimensions  and  number 
are  very  variable. 

The  lesions  may  occur  anywhere,  but  especially  on  the  scalp  and 
the  neighboring  skin,  on  the  neck,  the  upper  part  of  the  trunk,  the 
axillae,  the  groins,  the  articular  folds  in  general  and  more  rarely  on 
the  extremities. 

Sometimes  the  eruption  is  profuse,  more  or  less  symmetrically 
arranged,  appearing  in  rather  rapid  attacks  and  composed  of 
lenticular,  nummular,  or  more  extensive  plaques,  usually  marginate, 
dotting  the  thorax  and  the  abdomen.  Up  to  a  certain  point,  this 
variety  can  be  recognized  in  the  description  of  circinate  and  marginate 
pityriasis  (Vidal),  of  herpes  tonsurans  maculosus  (Hebra,  Kaposi) 
and  of  psoriatif orm  parakeratosis  in  scattered  patches  (Brocq) .  It 
approximates  the  pityriasis  rosea  of  Gibert.  In  the  absence  of  treat- 
ment, its  duration  is  from  a  few  weeks  to  several  months. 


94 


ERYTHEMA  TO-SQ  UA  MO  US  DERMA  TOSES 


In  other  cases  the  lesions  are  not  numerous,  localized  without 
symmetry,  limited  for  instance  to  a  large  articular  fold,  developing 


Fig.   16. — Pityriasiform  eczematides. 


I   [G.     17. 


-Pityriasiform  eczematide,  with  a  lichenoid  tendency,  located  on  the 
posterior  border  of  the  righl  axilla  in  a  young  woman. 


insidiously,  gradually  acquiring  ;i  rather  considerable  extent  and 
persisting  indefinitely.  The  spots,  from  being  at  first  simply  con- 
gestive and  furfuraceous,  may  assume  a  lichenoid  appearance,  or 


ECZEMATIDES 


95 


pass  into  a  psoriatiform  type;  they  are  apt  to  present  a  marginate 
or  circinate  outline  with  a  yellowish  center. 

In  both  cases,  but  especially  in  the  localized  variety,  the  pityriasi- 
form  eczematides  may  become  temporarily  vesicular  or  oozing 
(eczematized  seborrhoids  of  some  authors) ;  then  they  subside  again, 
unless  they  continue  to  develop  into  moist  eczema. 


Fig.  18. — Psoriatiform  eczematides  on  the  hip  of  a  middle-aged  woman;  note 
that  on  the  trunk  the  lesions  become  confluent,  as  erythrodermia. 

3.  Psoriatiform  Eczematides. — Their  topography  and  the  configu- 
ration of  the  lesions  are  entirely  analogous  to  the  preceding  form. 
But  the  spots  have  a  brighter  red,  or  tawny  hue  with  a  slightly 
infiltrated  base,  profusely  covered  with  more  or  less  adherent  white 
scales.  When  subjected  to  the  systematic  scraping1  of  Brocq,  they 
yield,  however,  less  numerous  and  less  stratified  lamellae  than  the 


1  The  "grattage  methodique"  of  Brccq  consist  in  the  careful  scratching  of  the 
surface  of  a  lesion  with  the  aid  of  a  dull  curette;  the  resulting  oozing,  bleeding, 
purpura,  etc.,  vary  in  a  characteristic  manner  in  different  diseases. — Ed. 


90  ERYTHEMATOSQUAMOUS  DERMATOSES 

spots  of  psoriasis;  the  red  surface,  on  exposure,  is  slightly  irregular 
and  scattered  over  with  purpuric  spots,  fine  hemorrhages,  and  cup- 
shaped  depressions  from  which  a  little  serous  fluid  exudes,  these 
depressions  representing  a  pathognomonic  feature.  The  lesions  of  a 
psoriatiform  eczematide  may  be  fairly  abundant,  covering  a  con- 
siderable portion  of  the  integument  (Fig.  18)  and  even  becoming 
regionally  confluent  in  large  erythrodermic  patches,  covered  with 
scaly  crusts;  often  they  are  few  in  number,  or  there  may  be  only 
a  single  large  patch  on  any  part  of  the  body;  for  instance,  on  the 
neck,  in  a  fold,  or  on  the  calf  of  the  leg. 

In  this  variety,  moist  eczematization  with  formation  of  vesicles, 
oozing  and  even  impetiginization  or  lichenization  is  not  uncommon. 

Itching  may  be  very  severe,  a  symptom  which  may  lead  to  pos- 
sible confusion  with  a  partial  prurigo. 

There  exists  finally,  (4)  a  peripilar  type  and  (5)  an  erythrodermic 
type  of  eczematides,  which  will  be  discussed  in  the  chapter  dealing 
with  the  folliculoses  (p.  395)  and  the  erythrodermas  (p.  120). 

Diagnosis. — This  is  by  no  means  easy  in  all  cases.  A  little  atten- 
tion will  suffice,  however,  in  the  case  of  figured  eczematides,  to  avoid 
confusion  with  a  desiccated  impetigo,  with  circinate  syphilides,  with 
lupus  erythematodes,  etc. 

Pityriasiform  eczematides  are  distinguished  from  pityriasis  rosea 
of  Gibert  by  the  often  larger  dimensions  of  their  lesions  and  by  the 
less  systematic  evolution  of  the  eruption.  There  are  borderline 
cases,  however,  in  which  the  question  arises  if  a  legitimate  distinc- 
tion can  be  drawn  between  the  two  types  of  disease.  Other  cases 
suggest  a  cutaneous  trichophytosis;  the  latter  is  characterized  by 
the  perfect  roundness  of  the  spots,  by  their  marginal  vesiculation 
and  by  the  demonstration  of  the  mycelium  on  microscopical  exami- 
nation of  the  scales.  Syphilitic  roseola  is  never  scaly.  In  psoriasis, 
even  when  mild,  the  scales  are  more  profuse. 

The  variety  with  large  patches  is  suggestive  of  intertrigo-erythema, 
of  eczema  marginatum  of  Hebra  and  of  erythrasma;  it  simulates 
especially  a  circumscribed  eczematized  prurigo.  When  it  presents 
oozing,  crusts,  lichenization  and  many  erosions,  the  diagnosis  can 
sometimes  not  be  made  until  after  treatment  for  several  days. 

Between  the  psoriatiform  eczematides  and  genuine  psoriasis,  there 
is  no  definite  objective  difference;  the  distinctive  features  are  based 
on  the  topography  of  the  eruption,  its  course,  its  tendency  to  oozing 
and  on  the  effect  of  treatment;  the  diagnosis  in  a  given  case  must 
sometimes  lie  held  in  abeyance. 

Pathological  Anatomy.  Although  somewhat  dissimilar  at  first 
sight,  the  histological  lesions  of  the  eczematides  are  always  of  the 
same  kind,  no  matter  what  variety  be  studied,  and  all  transition 
forms  are  met  with  between  these  varieties. 


ECZEMATIDES 


97 


The  essential  lesions  are:  Spongiosis,  in  small  foci;  parakeratosis, 
often  discontinuous;  scaly  crusts;  acanthosis;  in  the  cutis  a  little 
edema  with  perivascular  infiltration. 


Fig.  19. — Section  of  figured  eczematide.  X  27.  The  central  portion  of  the 
nummular  spot  is  not  shown  in  the  sketch,  only  the  two  borders  of  the  lesion  being 
represented.  A,  spongiosis;  B,  crust;  C,  parakeratosis;  D,  acanthosis;  E,  crust;  F, 
spongiosis. 

In  the  figured  form  (Fig.  19),  provided  the  lesion  is  in  active 
progression  and  not  at  a  stationary  stage,  as  frequently  happens, 
very  minute  foci  of  spongiosis,  too  small  to  constitute  vesicles 
visible  to  the  unaided  eye  may  be  seen  near  the  borders  or  more 
rarely  in  the  center.  Originating  in  the  rete,  these  foci  are  pushed 
up  in  the  course  of  the  epidermal  development  as  far  as  the  horny 
layer,  when  their  desiccated  plasma  mixed  with  the  layers  of  para- 


Fig.  20. — Psoriatiform  eczematide.  Entire  section  of  a  very  small  lesion.  X  30. 
A,  spongiosis;  B,  focus  of  desiccated  spongiosis;  C,  scale  crust;  D,  parakeratosis;  E, 
spongiosis;  F,  parakeratosis;  G,  spongiosis;  H,  papillary  edema  and  congestion;  I, 
cellular  infiltration. 


keratotic  cells  gives  rise  to  small  lenticular  crusts;  the  latter,  in  spite 
of  their  oily  consistence,  contain  less  fat  demonstrable  by  osmic  acid 
than  the  normal  horny  layer.  In  the  center  of  the  spots  only  a  low 
degree  of  acanthosis  is  found.  Edema  of  the  papillary  body  and 
perivascular  cellular  infiltration  are  marked  only  near  the  borders, 
which  are  abrupt  or  gently  sloping. 

The  psoriatiform  variety  simulates  psoriasis,  histologically  (Fig. 


98  ERYTHEMATO-SQUAMOUS  DERMATOSES 

20)  as  well  as  clinically.  The  differences  are  as  follows:  The  super- 
ficial layer  is  a  thick  scaly  crust,  in  which  are  found,  between  the 
layers  of  nucleated  horny  cells  (scales),  collections  of  desiccated 
serum  and  leukocytes  (crusts).  The  parakeratosis  may  be  con- 
tinuous over  the  entire  lesions,  or  interrupted.  The  acanthosis  and 
lengthening  of  the  papillae  are  nearly  as  marked,  although  less  regular 
than  in  psoriasis;  the  crests  of  the  papillae  do  not  reach  so  near  to 
the  horny  layer.  In  the  papillary  body  very  small  foci  of  spongiosis 
may  be  discovered  here  and  there,  corresponding  to  a  more  abundant 
cellular  infiltration  in  the  adjacent  papillae.  These  are  the  foci  of 
spongiosis  which  are  destined  to  become  crusts  on  reaching  the  horny 
layer.  The  papillary  edema  and  the  perivascular  cuffs  are  a  little 
more  pronounced  than  in  psoriasis  (Fig.  23). 

Summarizing,  these  lesions  constitute  an  epidermo-dermatitis  of 
eczema  type,  but  more  discrete,  less  acute  and  less  edematous.  It 
will  be  readily  understood  that  the  exaggeration  of  the  process  will 
result  in  eczema  vulgare. 

Etiology.— Eczematides  are  extremely  common.  They  are 
observed  at  all  ages,  especially  in  the  course  of  adolescence,  youth 
and  maturity.  Many  persons  suffer  from  the  affection  without 
attaching  importance  to  it.  A  considerable  number  of  eczemas  are 
derived  from,  or  begin  under  this  form. 

Clinical  analysis  had  formerly  led  to  the  conclusion  that  the 
dry  figured  eczemas  are  parasitic.  According  to  Unna,  seborrheal 
eczema  is  due  to  morococci,  micrococci  found  in  the  crusts  in  mul- 
berry-shaped clusters.  Others  believe  that  the  seborrhea  provokes 
eczema  (Dubreuilh),  or  creates  the  necessary  soil,  hence  the  name  of 
seborrhoids.  Audry  and  Brocq,  who  proposed  the  last  denomination, 
have  demonstrated,  however,  that  these  eruptions  can  exist  without 
seborrhea. 

The  relations  between  the  eczematides  and  kerosis  have  been 
discussed  above.  In  my  opinion,  kerosis  creates  a  peculiar  predis- 
position for  the  attenuated  eczematization  which  constitutes  the 
eczematides.  In  all  probability,  the  complication  is  the  result  of  a 
local  mierobic  infection.  The  responsible  species  is  not  yet  known, 
whether  it  be  the  staphylococcus  cutis  communis  or  the  poly- 
morphous coccus  with  gray  cultures  (Sabouraud),  or  other  staphy- 
lococci; nor  do  we  know  if  a  certain  degree  of  virulence  is  essential, 
or  a  certain  symbiosis,  for  example,  with  the  spores  of  Malassez 
(bottle-bacillus  of  Unna,  microsporon  anomaon  of  Vidal),  or  if 
there  exists  a  specific  microorganism  which  has  so  far  escaped 
detection.  Recent  investigations  of  Du  Hois  (Geneva)  on  this 
subject  indicate  that  the  scale  of  the  young  lesions  of  pityriasiforrn 
eczematides-  which  can  always  be  lifted  as  a  whole  with  a  scarifier 
or  a  fine  bistoury — bears  on  its  deep  aspect  collections  of  round 


PITYRIASIS  ROSEA  OF  GIBERT  99 

spores,  of  different  dimensions  and  without  mycelium;  he  was  unable 
to  grow  cultures  of  this  parasite  or  to  inoculate  the  germ,  which  is 
probably  identical  with  Vidal's  microsporon  anomceon  or  dispar. 
The  same  parasite  is  found  in  the  scales  of  the  pityriasis  rosea  of 
Gibert.    The  question  therefore  still  remains  open. 

Treatment. — Whereas  the  treatment  of  eczema  and  psoriasis  is 
difficult  and  often  disappointing,  the  eczematides  usually  yield 
favorable  results,  easily  obtained. 

In  the  sluggish,  especially  the  non-eczematized  forms,  treatment 
may  consist  of  rather  energetic  local  applications,  grading  the 
strength  of  the  remedy  according  to  the  intensity  of  the  lesions. 

It  is  often  advisable  first  to  clean  the  spots,  namely,  to  remove  the 
scales  or  crusts.  This  is  accomplished  by  means  of  soapy,  alkaline, 
or  sulphurous  baths,  by  moist  dressings,  or  more  simply  by  washing 
twice  daily  with  white  soap,  potash  soao,  or  a  sulphur  or  tar  soap. 

Directly  afterward,  or  simultaneously,  local  agents  are  employed, 
salves,  plasters  and  especially  compound  pastes,  whose  active  sub- 
stances are  selected  from  the  reducing  agents:  arsenic-zinc-sulphur 
paste  or  if  this  be  thought  too  irritant,  ichthyol  paste,  or  glycerol 
preparations  with  ichthyol  may  be  employed.  More  powerful 
reducing  agents  may  also  be  used  such  as  chrysarobin  or  pyrogallol 
in  very  small  doses. 

The  psoriatiform  eczematides  sometimes  offer  considerable  resis- 
tance to  treatment.  They  are  managed  like  psoriasis  but  with 
doses  of  progressively  increasing  strength,  and  cautiously  for  fear 
of  exciting  acute  eczematization.  Compounds  of  tar  and  sulphur, 
for  example,  and  radiotherapy  constitute  very  valuable  adjuvants 
in  difficult  cases. 

On  the  scalp,  sulphur  lotions  are  employed,  with  ointments 
containing  the  same  active  substance. 

Internal  treatment,  by  diet  and  medicinal  agents,  plays  practically 
no  part  in  the  eczematides;  or  rather,  it  is  identical  with  that  of 
kerosis. 

PITYRIASIS  ROSEA  OF  GIBERT. 

Pityriasis  rosea  of  Gibert — pityriasis  maculata  et  circinata  of 
Duhring,  roseola  squamosa  of  Fournier,  herpes  tonsurans  maculosus 
of  Kaposi — is  an  erythemato-squamous  dermatosis,  characterized 
(1)  by  its  lesions;  (2)  by  its  topographical  distribution;  and  (3) 
especially  by  its  course. 

Symptoms. — The  eruption,  which  itches  severely,  slightly  or  not 
at  all,  consists  of  two  kinds  of  lesions.  Some  are  pinkish,  scaly, 
irregularly  rounded  lenticular  or  nummular  spots,  with  not  abso- 
lutely distinct  margins;  they  may  become  confluent  in  plaques  or  in 
patches, 


100  ERYTHEMATOSQUAMOUS  DERMATOSES 

The  others  are  more  characteristic;  known  as  "medallions,"  they 
are  larger,  almost  invariably  elliptical,  pinkish  and  squamous  on 
their  slightly  elevated  borders  and  have  a  yellowish  center  where 
the  epidermis  is  finely  puckered  as  in  atrophic  strife.  These  two 
kinds  of  lesions  are  present  in  variable  proportions:  the  larger 
lesions,  "medallions"  may  be  rare  and  have  to  be  looked  for  or  they 
may  be  absent  at  a  given  moment. 

Pityriasis  rosea  may  occupy  the  entire  trunk,  the  neck  and  the 
limbs,  but  it  almost  invariably  spares  the  face  above  the  chin,  the 
hands  and  the  feet.  The  immunity  of  the  hairy  scalp  is  worthy  of 
special  mention .  The  susceptible  regions  are  not  affected  all  at  once, 
but  symmetrically  and  nearly  always  in  a  certain  order. 

The  course  of  this  affection  is  one  of  its  most  peculiar  features. 
The  disease  is  almost  definitely  cyclic,  so  that  pityriasis  rosea  has 
been  described  as  a  pseudo-exanthema. 

Frequently — as  was  first  pointed  out  by  Brocq — the  eruption  is 
introduced  by  a  primary  patch,  or  initial  plaque,  occupying  any 
portion  of  the  trunk,  neck,  or  limbs.  It  is  erythemato-squamous, 
fairly  well  outlined,  more  or  less  pruritic,  often  circinate,  and  is 
usually  misinterpreted  as  a  patch  of  trichophytosis  or  an  eczematide. 
Two  or  three  such  patches  may  be  present.  Judging  from  my 
persona]  experience,  the  initial  plaque  remains  undetected,  or  is 
entirely  absent,  in  about  one-half  of  the  cases. 

From  four  to  twenty  days  later,  or  sometimes  from  the  start,  the 
pinkish  spots  and  "medallions"  appear  in  profuse  crops,  first  on  the 
upper  part  of  the  thorax,  on  the  neck  and  arms,  then  on  the  flanks, 
the  abdomen  and  the  thighs,  finally  on  the  forearms  and  sometimes 
on  the  legs. 

The  eruption  is  accordingly  successive,  progressive  and  descend- 
ing. It  is  afebrile  and  unaccompanied  by  disturbances  of  the 
general  health. 

At  the  end  of  a  month  to  six  weeks,  two  and  a  half  months  at 
most,  the  spots  which  begin  to  fade  in  the  regions  first  affected, 
disappear  completely  without  leaving  a  trace  behind. 

1  have  observed  a  recurrence  of  pityriasis  rosea  at  the  end  of  four 
years  in  the  same  patient,  but  this  is  very  exceptional. 

Pathological  Anatomy. — The  pathological  anatomy  reveals  more 
lesions  than  might  have  been  anticipated.  Aside  from  a  congestion 
of  the  papillary  body,  with  edema  and  rather  marked  perivascular 
cellular  infiltration,  Sabouraud  has  pointed  out  the  regular  presence 
in  the  border  of  the  spots,  of  microscopical  foci  of  spongiosis  and 
numerous  superficial  histological  vesicles.  The  latter  are  never 
clinically  demonstrable  and  contain  only  mononuclear  leukocytes, 
but  apparently  no  microorganisms. 


PITYRIASIS  ROSEA  OF  GIBERT  101 

The  scales  are  parakeratotic  and  interspersed  with  these  desiccated 
vesicles.  No  mycelium  or  special  parasites  are  demonstrable  and  a 
remarkable  confusion  has  led  Hebra  and  Kaposi  to  describe  pity- 
riasis rosea  as  a  trichophytosis,  under  the  name  of  herpes  tonsurans 
maculosus. 

Diagnosis. — Pityriasis  rosea  of  Gibert  differs  from  the  eczematides, 
by  its  "medallions,"  by  its  symmetrical  distribution,  by  its  invariable 
absence  from  the  scalp,  and  especially  by  its  regular  and  cyclic 
development,  which  terminates  in  spontaneous  cure  in  a  definite 
time — though  sometimes,  the  immediate  diagnosis  must  be  left 
open;  from  psoriasis,  by  its  much  less  vivid  redness,  its  fine  non- 
stratified  scales  and  its  course;  from  toxic  and  infectious  erythemas, 
by  its  "medallions"  and  its  desquamation. 

An  unpardonable  error,  one  that  may  lead  to  great  domestic  dis- 
tress, is  unfortunately  sometimes  committed,  when  a  case  of  pity- 
riasis rosea  is  mistaken  for  a  syphilitic  roseola;  the  latter  is  never 
scaly,  does  not  form  "medallions"  and  is  associated  with  a  hard 
chancre,  mucous  patches  or  at  least  with  glandular  enlargement. 

Etiology  and  Character. — As  to  its  nature  and  cause,  pityriasis 
rosea  remains  a  problem.  It  is  known  preferably  to  attack  youthful 
individuals,  especially  young  girls  and  women;  to  be  more  common 
in  the  spring  and  fall  and  in  persons  suffering  from  digestive  dis- 
turbances.   It  shows  no  predilection  for  cases  of  kerosis. 

Its  initial  plaque,  its  course,  its  spontaneous  cure  after  a  certain 
lapse  of  time  and  its  non-recurrence,  speak  in  favor  of  a  systemic 
infection .  No  instances  of  contagion  are  known .  Long  ago,  Lassar 
advanced  the  view  that  pityriasis  rosea  might  result  from  an  exog- 
enous cutaneous  infection,  the  unknown  germ  being  transmitted 
by  new  or  bleached  underwear;  Jadassohn  believes  this  view  to  be 
justified  in  a  number  of  the  cases. 

Treatment.— It  is  better  to  omit  all  treatment  of  an  eruption  which 
always  heals  spontaneously  than  to  aggravate  it  by  the  use  of  soap, 
sulphur  baths,  or  irritative  topical  applications  which  congest  the 
skin,  aggravate  the  pruritus  and  sometimes  give  rise  to  a  real  eczema- 
tization. 

Dusting  with  a  bland  powder  may  suffice.  It  has  seemed  to  me 
that  coal-tar  in  small  doses,  particularly  ichthyol,  2  per  cent,  in  a 
cream  or  a  glycerol,  visibly  hastened  the  fading  of  the  lesions. 
Jadassohn  recommends  chrysarobin  pastes  of  very  weak  concen- 
tration (1  in  3000  to  1  in  1000);  others  prefer  sulphur  pastes,  or 
especially  aqueous  pastes.  [Calamine  lotion  with  the  addition  of 
10  per  cent,  of  precipitated  sulphur,  or,  in  very  pruritic  cases,  of  2  per 
cent,  of  phenol  is  a  satisfactory  application.] 


102  ERYTHEMATOSQUA  MOl  rS   DERMATOSES 

PSORIASIS. 

Psoriasis  is  one  of  the  most  important  dermatoses,  through  its 
frequency,  the  multiplicity  and  extent  of  it^  lesions  and  its  rebellious 

character. 

Symptoms.  'Die  lesion  of  psoriasis  is  typical.  In  its  most 
common  form,  it  is  a  bright  red,  sharply  circumscribed  spot,  covered 
with  dry,  nacreous,  laminated,  friable  and  abundant  scales;  the 
base  of  the  spot  is  not  infiltrated  and  there  is  no  itching  (Fig.  21). 

Scratching  these  lesions  causes  two  characteristic  signs:  (1)  on 
scratching  with  the  fingernail,  the  scale  breaks  down  into  a  fine 
white  micaceous  dust;  (2)  after  the  scale  has  been  removed  by  the 
fingernail  a  red  shining  surface  is  exposed  showing  fine  punctiform 
hemorrhages. 


Fig.   21. — Nummular  psoriasis  "ii   the   wrist,  large  plaque  on  the  forearm,   with 
psoriatic  arthropathies  of  the  hand  ami  fingers. 

The  last-named  sign,  known  as  Auspitz'  sign,  the  importance  of 
which  was  shown  by  Hebra  and  Devergie,  has  been  more  fully 
analyzed  and  worked  out  by  L.  Duncan  Bulkley  and  by  the  recent 
investigations  of  Brocq.    It  will  he  again  referred  to  later. 

It  i>  frequently  demonstrable,  on  careful  inspection,  that  the 
psoriasis  >pots  arc  surrounded  1>,\  a  [talc  halo,  from  1  to  8  mm.  wide, 
the  skin  of  which  i>  healthy,  hut  slightly  blanched. 

The  lesions  of  psoriasis  are  usually  rounded  or  oval  in  shape. 
They  may  be  of  au\  size  from  a  pin-point  or  pin-head,  a  drop  of 
wax,  or  a  coin,  to  immense  patches,  covering  an  entire  region  of  the 
body.  As  a  rule  the  lesions  of  the  same  eruption  have  rather  uni- 
form dimensions,  hence  the  terms  psoriasis  punctata,  [guttata], 
nummularis,  discoides,  etc.,  which  have  merely  a  descriptive  value. 

Sometimes,  the  lesions  have  the  shape  of  psoriatic  rings,  from 
\  to  1  cm.  wide,  enclosing  an  area  of  healthy  skin,  or  fragments  of 


PSORIASIS 


103 


rings  and  arabesque  designs,  constituting  psoriasis  gyrata  or  figurata, 
formerly  described  under  the  objectionable  name  of  lepra  vulgaris; 
or  they  may  be  marginate  plaques,  the  result  of  healing  from  the 
centre. 


Fig.  22. — Psoriasis,  general  topography  of  the  eruption. 


The  eruption  is  accompanied  by  no  general  disturbances;  psoriasis 
is  pruritic  only  in  inebriates  and  in  some  nervous  subjects. 

The  number  of  lesions  is  infinitely  variable,  from  a  few  isolated 
spots  to  several  hundreds.    The  eruption  at  its  origin  appears  either 


104  ERYTHEMATOSQUAMOUS  DERMATOSES 

as  minute  red  papules  which  fade  even  on  scratching,  or  as  concen- 
trically growing  guttate  lesions  which  rather  rapidly  reach  their 
permanent  dimensions,  or  primarily  as  patches  of  nummular  size. 

In  its  distribution,  typical  psoriasis  shows  a  marked  tendency  to 
symmetry  and  a  predilection  for  bony  prominences  (Fig.  22);  the 
elbows  and  the  knees,  the  scalp  and  the  sacrum  (sacral  plaque)  are 
especially  the  seats  of  the  largest,  most  typical  and  most  obstinate 
patches.  However,  all  regions  of  the  integument  including  the  face, 
the  palms  and  the  soles,  the  red  border  of  the  lips,  and  the  semi- 
mucosse  of  the  genital  organs  may  be  affected,  but  the  mucous 
membranes  are  always  free.  The  "buccal  psoriasis"  of  the  older 
authors  is  simply  leukoplakia  (p.  219). 

On  the  scalp,  which  rarely  escapes  and  is  sometimes  the  sole  seat 
of  the  affection,  the  psoriasis  spots  or  patches  are  characterized  by 
their  sharp  limitation,  the  abundance  of  white  or  grayish  scales,  in 
a  continuous  or  micaceous  layer,  covering  a  red  non-oozing  surface. 
It  is  noteworthy  that  the  hairs  are  preserved,  appear  dry,  pass 
through  the  scales  and  do  not  come  out  on  traction,  contrary  to 
what  happens  in  the  eczematides  of  this  region  and  in  the  tineas. 

Varieties. — There  occur  anomalies  of  eruptive  form  or  of  distribu- 
tion and  regional  varieties.  Sometimes  the  spots  of  psoriasis  are 
faintly  outlined,  superficial,  light  pink  and  covered  with  not  very 
profuse  slightly  yellowish  scales  resembling  pityriasis.  This  attenu- 
ated psoriasis,  which  is  often  seen  on  the  face  and  occasionally  on  the 
genital  organs,  is  sometimes  difficult  to  distinguish  from  the  eczema- 
tides. 

Psoriasis  spots,  even  when  small,  may  exceptionally  have  a  slightly 
infiltrated  base,  solid  to  the  touch  and  almost  papular;  representing 
infiltrated  psoriasis.  This  modification  occurs  especially  at  the 
border  of  the  annular  and  carcinate  lesions  of  figured  psoriasis. 
Somewhat  extensive  spots  or  patches  of  long-standing  psoriasis  are 
always  more  or  less  thickened  and  sometimes  even  lichenoid: 
psoriasis  inveterata.  In  certain  regions,  for  example,  on  the  legs, 
the  surface  exceptionally  becomes  roughened  or  papillomatous. 
Frequently,  old  and  figured  patches  are  covered  with  a  nacreous, 
oystershell-like  keratotic  layer  of  stratified  and  adherent  scales. 

In  other  cases,  especially  in  the  articular  folds,  psoriasis  may  have 
the  appearance  of  vivid  red  plaques,  denuded  of  scales,  or  covered 
with  crusts,  or  freely  oozing  like  an  eczema  rubrum;  the  borders  are 
sometimes  irregular.  The  nature  of  this  oozing  psoriasis,  or  eczema- 
psoriasis  of  the  old  authors,  is  doubtful.  Are  these  cases  a  special 
form  of  psoriasis,  or  are  they  an  eczematized  psoriasis,  even  though 
the  integument  of  such  patients  is  usually  very  rebellious  to  artificial 
eczematization;  or  are  they  a  psoriatiform  eczematide?  It  seems 
probable  that  there  are  cases  to  which  each  of  these  interpretations 


PSORIASIS  105 

may  be  applied.  It  is  not  uncommon  to  find  typical  spots  of  psoriasis 
on  the  elbows  and  knees  of  these  patient. 

In  some  cases  of  genuine  psoriasis,  the  almost  exclusive  localiza- 
tion on  the  flexor  surfaces  of  the  articular  folds,  the  groins,  axillae, 
as  well  as  on  the  genitals  and  often  on  the  palms  and  soles,  con- 
stitute a  type  known  as  psoriasis  inversa.  The  eruption  assumes  the 
form  of  large  bright  red  patches,  the  skin  being  smooth  and  tense. 
It  is  found  in  the  victims  of  diabetes,  overexertion  or  intoxication. 
It  is  often  very  obstinate  and  apt  to  become  irritated  by  any  form 
of  medication. 

This  variety  more  often  than  the  typical  forms,  becomes  associated 
with  secondary  erythrodermas  of  the  benign  or  malignant  "herpe- 
tide"  type  (p.  122);  sometimes,  the  onset  of  this  complication  is 
attributable  to  badly  tolerated  medicinal  applications. 

The  distribution  which  is  indicated  in  the  names  of  palmar  and 
plantar  psoriasis  (p.  215);  ungual  psoriasis  (p.  435)  and  psoriasis 
universalis  (p.  120),  will  be  described  in  other  chapters. 

A  very  important  clinical  form  because  undoubtedly  the  most 
serious,  is  the  arthropathia  psoriasis,  studied  especially  by  Bourdillon. 

The  frequency  of  articular  manifestations  in  psoriasis  is  estimated 
at  5  per  cent,  of  the  cases;  and  in  my  opinion  this  estimate  is  too  low. 
[They  are  by  no  means  so  frequent  in  America].  Often,  these  are 
merely  arthralgias,  myalgias  and  melalgias,  resembling  indefinite 
subacute  rheumatism;  this  is  psoriasis  dolorosa.  In  other  cases, 
either  dating  from  the  first  eruption  or  after  the  lapse  of  a  few 
years,  progressive  nodular,  bony  or  fibrous  arthropathies  super- 
vene, affecting  the  joints  of  several  fingers  (Fig.  21),  one  or  more 
large  joints  and  sometimes  entire  limbs  and  the  vertebral  column, 
leading  to  deformities  with  ankylosis  and  contractions  which  con- 
stitute most  painful  and  deplorable  infirmities. 

The  differential  feature  of  these  arthropathies  from  those  of  mul- 
tiple arthritis  deformans — with  which  they  have  many  analogies — 
aside  from  their  coincidence  with  the  eruption,  is  their  predilection 
for  the  male  sex,  youths  and  adults  rather  than  old  men,  their  more 
abrupt  course,  the  frequent  presence  of  hydrarthroses  and  the  pre- 
dominance of  swelling  among  the  deformities;  finally,  the  absence 
of  all  regularity  of  the  invasion.  These  features  likewise  charac- 
terize the  tuberculous  pseudo-rheumatism  of  Poncet. 

Arthropathic  psoriasis,  being  too  common  to  admit  of  an  explana- 
tion by  simple  coincidence,  constitutes  an  argument  for  certain 
authors  in  favor  of  a  nervous  origin,  for  others  (Audry,  Petges,  etc.) 
in  favor  of  the  tuberculous  origin  of  psoriasis,  or  rather  of  certain 
forms  of  psoriasis. 

Course. — Psoriasis  runs  its  course  in  more  or  less  abrupt  attacks 
in  different  cases  and  is  of  very  variable  duration.    The  first  attack 


100  ERYTHEMATOSQUAMOUS  DERMA  TOSES 

is  often  more  acute  and  composed  of  many  small  lesions,  but  this  is 
not  an  absolute  rule.  Subsequent  attacks  supervene  without  any 
regularity  and  often  in  the  absence  of  a  demonstrable  determining 
cause. 

In  the  interval  between  attacks,  especially  under  the  influence  of 
appropriate  treatment,  the  patient  is  "bleached,"  in  the  sense  that 
the  lesions  fade,  sometimes  leaving  a  dark  deep-pigmented  macule 
which  persists  a  few  months  before  it  disappears.  Such  patients, 
however,  are  by  no  means  to  be  considered  as  cured. 

Sometimes,  two  or  three  more  obstinate  spots  resist  all  therapeutic 
efforts  and  persist  indefinitely.  It  is  moreover  in  the  nature  of  the 
disease  to  recur  during  almost  the  entire  lifetime  of  the  patient. 
The  skin  rarely  remains  perfectly  free  for  more  than  two  or  three 
years  in  these  cases.  There  are  innumerable  cases  of  discrete  psoriasis, 
without  severe  attacks,  but  incessantly  persistent  or  recurrent. 

In  aged  persons,  the  disease  becomes  attenuated  or  extinct,  some- 
times leaving  behind  it  a  sort  of  persistent  pityriasic  desquamation. 

Diagnosis. — This  is  based  on  the  characteristic  features  of  the 
lesions,  those  of  the  eruption  and  of  the  disease.  The  properties 
belonging  to  the  psoriasis  spot  cannot  be  over-emphasized.  Their 
recapitulation  here  is  unnecessary,  but  on  account  of  their  great 
importance,  I  must  refer  again  to  the  data  furnished  by  systematic 
grattage  according  to  the  method  of  Brocq. 

In  a  typical  lesion  of  psoriasis,  under  the  successive  layers  of 
micaceous  scales,  a  red  and  smooth  surface  is  reached,  from  which 
a  fine  pellicle  can  be  detached,  coming  off  in  shreds  several  centi- 
meters square;  underneath  it  fine  droplets  of  blood  exude,  sometimes 
after  a  little  lapse  of  time;  but  purpuric  spots  are  rare  and  no  drops 
of  serous  fluid  are  obtained,  as  in  the  eczematides. 

As  regards  the  eruption,  without  referring  to  its  customary  dis- 
tribution, it  is  to  be  noted  that  in  psoriasis,  all  the  lesions  are  psorias- 
iform, a  condition  which  is  not  found  in  the  diseases  which  simulate 
it  (psoriatiform  syphilides,  etc.). 

It  would  be  superfluous  to  dwell  on  the  differential  features  dis- 
tinguishing psoriasis  from  lichen  planus,  lichen  corneus,  premycotic 
patches,  Lupus  erythematodes,  pityriasis  rubra  pilaris  and  the  other 
erythemato-squamous  dermatoses  treated  in  this  chapter;  these 
differences  will  be  manifest  from  the  description  of  these  various 
affections. 

Pathological  Anatomy. — The  principal  lesion  of  psoriasis  is  para- 
keratosis, or  change  of  keratinization  characterized  by  the  disappear- 
ance of  the  stratum  granulosum  and  by  the  persistence  of  flattened 
nuclei  in  the  cells  of  the  horny  layer.  The  horny  layer  is  also  less 
oily  than  in  the  normal  state,  its  stratifications  accumulate,  but  are 
easily  split  into  lamellae  (Fig.  23). 


PSORIASIS  107 

The  rete  is  hypertrophied  and  considerably  thickened  (acanthosis) 
between  the  papilla?  which  are  greatly  elongated  and  cylindrical 
(papillomatosis) ;  but  it  is  thinned  above  the  crests  of  these  papillae 
which  are  separated  from  the  parakeratotic  horny  layer  only  by  a 
few  layers  of  flattened  cells.  The  papilla?  and  the  papillary  body  are 
slightly  edematous  and  their  bloodvessels  are  dilated  and  surrounded 
by  a  small  number  of  round  cells;  the  lesions  of  the  derma  are  insig- 
nificant. 


..         <   '.     '    :.'     :V 


Fig.   23. — Histology  of  psoriasis.    General  section  of  a  small  but  long  standing 
lesion  of  the  elbow.      X  50.     A,  parakeratosis;  B,  acanthosis;  C,  papillomatosis;  D, 


These  changes  explain  the  clinical  symptoms;  the  redness  is  refer- 
able to  the  congestion,  to  the  elevation  of  the  papillary  crests  and 
to  the  absence  of  an  opaque  keratohyaline  layer.  The  desquamation 
and  the  peculiar  powdery  scaling  evident  upon  scratching  depend 
upon  the  cleavage  and  the  friability  of  the  parakeratotic  horny  layer. 
The  smooth  sub-squamous  membrane  is  made  up  of  the  layers  of 
flattened  Malpighian  cells;  it  is  due  to  the  slight  thickness  of  this 
layer  and  its  softness  that  the  adjacent  vascular  papilla?  are  easily 
injured  with  the  nails,  whence  the  punctiform  hemorrhages.  Acan- 
thosis and  infiltration  are  more  marked  in  inveterate  psoriasis  with 
more  or  less  lichenoid  patches. 

The  parakeratosis,  owing  to  which  the  epidermis  is  now  composed 
of  only  two  layers,  like  that,  for  instance,  of  orificial  mucosa,  is  not 
specific  for  psoriasis.  It  is  the  substratum  of  many  forms  of  des- 
quamation especially  of  the  psoriasiform  type;  it  is  observed,  for 
example,  in  the  dermatitides,  in  recent  cicatrices,  after  the  spongiosis 
of  eczema  and  the  eczematides,  in  the  psoriatiform  syphilides,  etc. 

In  psoriasis  itself,  it  is  apparently  only  secondary.  The  investi- 
gations of  Munro  (1898)  and  of  Sabouraud,  confirmed  by  those  of 
Paul  Haslund  (1913)  have  shown  that  aside  from  the  lesions  of  the 


108  ERYTHEMATOSQUAMOUS  DERMATOSES 

stationary  stage  which  I  have  described,  small  miliary  abscesses 
containing  leukocytes  but  without  demonstrable  microbes,  may  be 
observed  in  incipient  or  progressing  psoriasis;  these  minute  abscesses 
form  in  the  subcorneal  layer  of  the  rete  and  are  successively  pushed 
up  into  the  horny  layer  where  they  appear  as  a  layer  of  desiccated 
cells.  When  the  eruption  is  actively  progressing,  they  are  very 
numerous  and  succeed  one  another  rapidly  and  incessantly  at  the 
same  point  or  at  neighboring  points.  This  lesion  is  considered  by 
Sabouraud  as  pathognomonic  of  psoriasis  and,  reasoning  on  these 
premises,  he  groups  under  the  heading  of  psoriasis  more  than  half 
of  the  seborrhoids  or  eczematides.  The  minute  abscesses  of  psoriasis 
actually  bear  a  close  resemblance  to  the  small  foci  of  spongiosis 
which  I  have  emphasized  in  the  eczematides;  when  the  two  forms  of 
microscopic  lesions  are  confused,  the  histological  differentiation 
becomes  very  difficult  and  in  certain  cases  must  rest  on  a  single 
characteristic,  namely  the  extreme  paucity  of  microbes  taking  stains 
in  sections  of  psoriasis,  whereas  there  is  an  abundance  of  organisms 
in  the  eczematides. 

Etiology  and  Character.  —  Psoriasis  occurs  in  all  countries  and 
climates,  somewhat  more  frequently  in  men.  It  may  appear  at 
any  age,  from  two  to  eighty  years,  but  is  most  common  around  the 
period  of  puberty  and  during  adolescence.  [It  constitutes  from  3  to 
5  per  cent,  of  all  cases  seen  in  dermatological  practice.]  Psoriasis  is 
not  contagious.  It  seems  to  be  hereditary,  or  familial,  in  one- 
fifteenth  to  one-twentieth  of  the  cases. 

In  favor  of  its  external  parasitic  origin  have  been  urged  the  sharp 
limitation  and  the  centrifugal  development  of  its  lesions;  its  occur- 
rence, in  psoriatics,  in  localities  traumatized  by  vaccination,  tattoo- 
ing, friction  of  suspenders  or  other  tight  articles  of  clothing,  scratches 
made  with  a  pin;  a  feature  as  a  matter  of  fact  which  suggests  auto- 
inoculation.  Destot  (Lyons)  is  said  to  have  successfully  inoculated 
himself  with  psoriasis,  but  his  experiment  does  not  appear  convincing. 
Arguments  may  also  be  based  on  the  therapeutic  action  of  parasi- 
ticidal  topical  applications.  But  the  direct  examination  of  the 
minute  abscesses  invariably  shows  them  to  be  free  from  microbes 
and  in  the  scales  the  common  microbes  are  extremely  rare.  In  the 
studies  on  the  etiology  of  psoriasis  directed  by  J.  F.  Schamberg 
(1913)  no  special  microorganism  in  the  skin  or  the  blood  of  psoriatics 
was  found.  The  parasitic  theory,  although  reasonable,  is  by  no 
means  proved. 

The  relations  of  psoriasis  with  arthritism  and  with  the  dyscrasias 
rest  on  a  few  facts,  but  are  neither  accurate  nor  demonstrable.  To 
describe  a  tendency  to  psoriasis  as  herpetism,  is  merely  a  play  on 
words. 

Too  rich  a  diet,  especially  in  albuminoid  substances,  seems  to  be 


PSORIASIS  109 

capable  of  favoring  the  first  appearance,  or  at  any  rate  the  eruptive 
outbreaks,  of  psoriasis. 

The  theory  of  the  nervous  origin  of  psoriasis  is  supported  by  the 
usual  symmetry  of  the  eruption,  its  occasional  appearance  in  con- 
nection with  a  serious  accident  or  emotional  shock,  the  coexistence 
of  neuralgias  and  arthropathies.  It  has  been  claimed  by  several 
observers  that  psoriasis  manifested  itself  relatively  often  in  the 
participants  of  the  late  war.  If  this  be  true  (which  is  doubtful), 
a  number  of  other  causes  besides  emotion  might  be  involved  (too 
much  meat,  etc.) 

Of  recent  years,  several  authors  have  advanced  the  view  of  a 
possible  connection  between  psoriasis,  or  certain  forms  of  psoriasis, 
and  attenuated  tuberculosis.  Although  it  is  certain  that  the  arthrop- 
athies of  psoriasis  present  marked  analogies  with  the  tuberculous 
rheumatism  of  Poncet,  the  great  majority  of  psoriatics  do  not 
convey  the  impression  of  being  the  subjects  of  tuberculosis.  Psoriasis 
and  tuberculosis  are  so  common,  moreover,  that  there  is  nothing 
remarkable  about  their  frequent  coincidence.  Brocq  groups 
psoriasis  under  his  "cutaneous  reactions,"  and  admits  that  it  may 
develop  under  the  influence  of  a  number  of  occasional  causes,  or 
without  this  influence  through  the  effect  of  disturbances  of  the 
general  conditions  not  yet  determined  by  chemical  analysis.  These 
indefinite  phrases  aptly  express  our  ignorance  concerning  the  true 
character  of  this  dermatosis. 

Treatment. — This  must  be  in  the  first  place  external  and  local. 
It  comprises  two  stages: 

1.  Cleansing. — It  is  indispensable  to  clean  and  free  the  patches 
from  their  scaly  covering  before  the  medicinal  agents  are  made  to 
act  upon  them.  This  is  accomplished  by  more  or  less  prolonged 
soapy,  alkaline,  or  tar  baths,  or  steam  baths,  or  by  moist  or  rubber- 
ized dressings.  In  most  cases  vaseline  or  glycerol  inunctions,  soft 
soap,  lard,  etc.,  are  used.  Salicylated  vaseline  (5  per  cent.)  with 
applications  of  green  soap  twice  daily,  seems  to  be  the  most  rapid 
procedure;  at  the  end  of  a  few  days,  we  may  pass  on  to  other 
remedies. 

2.  Reducing  Agents. — All  reducing  agents  (see  Therapeutic 
Notes)  are  capable  of  healing  the  patches  of  psoriasis.  Treatment  is 
begun  with  the  weakest,  with  the  tars,  especially  oil  of  cade  the 
virtues  of  which  have  long  been  tried,  in  the  form  of  salves,  glycerol- 
ated,  or  in  the  pure  state.  More  or  less  deodorized  and  decolor- 
ized extracts  have  been  prepared,  known  as  lenicade,  oxycade,  etc., 
which  are  liked  by  patients  [but  are  less  effective]. 

The  mercurials  (calomel,  turpeth  mineral,  etc.)  or  sulphur,  etc., 
are  reserved  for  the  scalp  and  the  face.  The  addition  of  salicylic 
acid  (1  per  cent.)  increases  their  action.    It  must  be  kept  in  mind 


110  ER  Y  THE  MA  TO-SQ  UA  MO  US  DERMA  TOSES 

that  a  mixture  of  sulphur  and  a  mercurial  salt  would  dye  the  hair 
and  the  same  remark  applies  to  naphthol. 

Strong  reducing  agents,  or  salves  containing  such  agents,  which 
are  efficient  but  irritating  should  not  he  employed  except  in  rather 
scanty  eruptions  and  when  the  patient  can  be  watched. 

Chrysarobin  is  the  best;  it  is  employed  as  an  ointment  with 
ichthyol,  or  preferably  as  a  varnish  with  traumaticine.  It  acts  only 
when  an  erythema  is  produced,  which  however,  must  remain 
moderate.  Alkaline  baths  and  washes  must  be  avoided  during  its 
use.  It  stains  the  hair  and  linen  a  violet  color  and  sometimes  gives 
rise  to  severe  conjunctivitis.  But  it  will  sometimes  bleach  a  case 
of  psoriasis  in  a   fortnight. 

Pyrogallic  acid,  in  salves,  varnishes,  or  in  ethereal  solutions,  will 
destroy  the  linen  and  blacken  the  epidermis  and  the  hair;  it  is  very 
efficacious  but  difficult  to  handle  on  account  of  the  danger  of  poison- 
ing when  it  is  employed  on  large  surfaces. 

Of  the  innumerable  chemical  products  extolled  abroad  as  anti- 
psoriatics,  none  seems  to  me  worthy  of  being  retained. 

Radiotherapy — the  indications  of  which  in  psoriasis  I  pointed 
out  in  1898— may  rapidly  obliterate  recent  or  even  inveterate 
patches  which  have  first  been  cleansed.  It  is  only  applicable, 
however,  in  circumscribed  eruptions,  and  does  not  prevent  recur- 
rences.   It  is  employed  only  in  exceptional  cases. 

3.  General  Treatment. — This  is  much  less  important.  Arsenic 
has  been  regarded  as  a  specific  and  administered  in  all  its  forms; 
moderate  doses  are  often  beneficial;  energetic  arsenical  medication 
subjects  the  patient  to  the  risk  of  intense  pigmentation  and  may 
produce  a  genuine  leuko-melanodermia.  The  arsenobenzols  are  free 
from  this  drawback  and  are  sometimes  very  successful  but  must  be 
handled  very  cautiously. 

Potassium  iodide,  in  enormous  doses  from  15  to  25  grams  daily  has 
been  advocated;  I  have  obtained  no  results  from  it.  Injections  of 
calomel,  or  of  yellow  oxide,  by  themselves  alone  have  sufficed  to 
cure  some  cases  of  typical  psoriasis  and  to  improve  markedly 
arthropathic  psoriasis;  unfortunately  they  are  not  reliable.  Experi- 
ments are  now  under  way  with  injections  of  sulphur  in  solution. 

It  goes  without  saying  that  proper  hygienic  measures  should  be 
recommended  with  abstinence  from  alcohol  and  stimulants.  Schain- 
berg  and  his  associates  (Philadelphia  Research  Laboratories)  have 
emphasized  a  habitual  nitrogen  retention  in  these  cases  and  the 
favorable  influence  of  a  vegetable  diet  poor  in  nitrogen,  as  pre- 
viously recommended  by  Bulkley,  Besnier  and  others. 

Warm  mineral  springs  and  sulphur  waters  are  useful  in  some 
cases. 


PARAPSORIASIS 


111 


PARAPSORIASIS. 

Under  this  provisional  name,  Brocq  in  1902  grouped  several  rare 
and  unclassifiable  dermatological  types,  characterized  by  non- 
pruriginous  erythemato-squamous  spots,  extremely  persistent  and 
rebellious  to  all  treatment. 

It  is  exclusively  the  objective  appearance  of  these  dermatoses 
which  led  to  their  mutual  approximation  to  psoriasis.  Their  origin 
and  character  are  unknown,  hardly  even  surmised,  and  probably 
variable. 

Three  types  are  distinguished: 

Parapsoriasis  Guttata. — This  eruption  is  disseminated  over  the 
trunk  and  limbs  in  faintly  pink  or  brownish-red  lenticular  spots, 
very  slightly  infiltrated,  covered  with  dry  adherent  scales,  com- 
parable to  a  sealing  wafer.  Scratching  of  these  spots  gives  rise  to 
fine  purpuric  puncta.  The  eruption  resembles  an  abortive  guttate 
psoriasis,  or  a  resolving  papulo-squamous  syphilide.  It  is  main- 
tained by  the  appearance  of  new  lesions,  originating  separately  or 
in  crops. 


Fig.  24. — Lichenoid  parapsoriasis  dating  back  four  years,  in  a  man  aged  thirty-two 

years. 


Parapsoriasis  Lichenoides. — This  type  differs  from  the  preced- 
ing by  the  more  papular,  more  infiltrated  and  less  psoriatiform 


112 


ER  J '  THEM  A  TO-SQ  UA  MO  US  DERMA  TOSES 


character  of  the  lesions.  These  appear  in  the  form  of  bright  pink, 
hemispherical  or  flattened,  glistening  and  non-scaly  papules;  later 
on,  the  lesion  becomes  purplish  and  bears  a  scale  which  seems  to  be 
imbedded  in  a  depression  of  the  papule;  finally  there  remains  only 
a  yellowish  macule  with  slight  atrophy  of  the  epidermis.  The  erup- 
tion is  scattered  over  the  trunk  and  the  limbs  or  is  arranged  in 
clusters  and  network;  it  is  not  at  all  pruritic.  The  reproduction  of 
the  lesions  during  years  in  the  same  regions  gives  the  skin  a  pecu- 
liarly mottled  appearance  (Fig.  24).  The  differential  diagnosis 
must  be  made  from  lichen  scrofulosum  and  other  tuberculides, 
lichen  planus,  syphilides  and  psoriasis.  The  cases  published  by 
Unna  [and  Pollitzer],  Jadassohn,  Xeisser,  Pinkus,  Crocker,  etc., 
under  the  names  of  parakeratosis  variegata,  lichen  psoriasis,  pity- 
riasis lichenoides  chronica,  etc.,  belong  to  the  first  two  forms. 


25. — Parapsoriasis  in  patches  of  thirty  years'  standing  on  the  flank  of  a  man, 
aged  forty-seven  years. 


Parapsoriasis  in  Plaques.  —It  consists  of  circumscribed  spots  or 
patches  of  a  yellowish  pink  or  wine  color,  with  few  or  no  scales,  non- 
infiltrated  and  oon-pruritic;  their  configuration  is  round,  oval,  zoni- 
i'oini,  annular  or  reticulate  (Fig.  25);  their  arrangement  varies 
slightly  from  year  to  year;  on  their  surface  the  texture  of  the  skin 
is  modified  and  the  normal  mosaic  more  marked.  The  eruption 
occupies  the  trunk  and  the  limbs.    It  resembles  the  eczematides, 


PSORIATIFORM  SYPHILIDES  113 

premycotic  plaques,  or  tertiary  syphilitic  erythemas.  This  type 
was  described  in  1897  by  Brocq,  and  later  by  J.  C.  White,  under  the 
name  of  pityriasic  erythroderma  in  disseminated  patches.  Crocker 
gave  this  form  the  name  of  xantho-erythroderma  perstans. 

The  histology  of  parapsoriasis,  very  carefully  studied  by  Civatte, 
presents  briefly  the  following  lesions :  Edema  and  congestion  of  the 
papillary  body,  with  perivascular  cuffs  consisting  especially  of  lym- 
phocytes, sometimes  collections  suggestive  of  lichen  scrofulosum;  a 
rather  atrophic  Malpighian  layer  with  small  areas  of  parakeratosis. 

Parapsoriasis  appears  at  all  ages,  especially  during  youth  and 
maturity,  its  duration  is  indefinite;  the  lesions  disappear,  while 
others  insidiously  supervene.  Its  nature  is  unknown;  in  some  of  the 
cases  the  patients  were  old  syphilitics;  on  the  other  hand,  the  theory 
maintained  by  Civatte,  according  to  which  the  disease  is  a  tuber- 
culide, is  based  on  strong  clinical  and  pathologico-anatomical  argu- 
ments. 

All  local  medication  is  ineffectual ;  injections  of  arsenical  prepara- 
tions and  of  mercury  have  seemed  to  me  useful  in  some  cases. 

PSORIATIFORM  SYPHILIDES. 

Strictly  speaking  erythemato-squamous  syphilides  do  not  exist. 
However,  as  it  is  always  in  connection  with  syphilis  that  the  question 
of  the  diagnosis  of  pityriasis  rosea,  psoriasis,  etc.,  arises,  and  as 
errors  are  frequent,  I  believe  the  insertion  of  the  following  para- 
graph will  be  useful. 

In  the  first  place,  let  me  point  out  that  syphilitic  roseola  is 
never  squamous  or  scaly  (A.  Fournier),  whereas,  pityriasis  rosea  and 
psoriasis  are  always  scaly. 

As  to  the  papular  syphilides  of  secondary  lues,  these  are  habitually 
slightly  scaly,  but  may  become  so  to  a  degree  which  entitles  them  to 
the  epithet  of  psoriatiform. 

Their  dimensions  are  miliary,  lenticular,  or  nummular;  their 
form  is  round,  orbicular,  sometimes  annular  in  certain  regions; 
their  color  is  pink  or  red,  but  often  dull,  purplish,  not  so  vivid  as 
the  lesions  of  psoriasis.  Although  desquamation  may  be  profuse, 
it  is  nevertheless  not  so  abundant  as  in  psoriasis;  scratching  reveals 
no  subcorneal  pellicle  and  very  readily  produces  traumatic  purpura. 

But  the  sign  par  excellence  of  the  syphilides,  on  which  the  diagnosis 
must  always  rest,  is  their  firm  resistant  infiltration,  their  hardened, 
neoplastic  consistence;  they  have  substance,  according  to  an 
expression  used  by  A.  Fournier.  The  lesions  of  recent  psoriasis, 
on  the  contrary,  are  pliable  and  not  indurated.  All  this  signifies 
that  in  spite  of  their  apparent  anology,  syphilis  really  produces 
squamous  papules,  whereas  psoriasis  gives  rise  to  squamous  macules. 

The  eruption  of  psoriatiform  syphilides  is  irregularly  scattered 


114  ERYTHEMATO-SQUAMOUS  DERMATOSES 

everywhere,  often  confluent  on  the  face,  the  back,  the  nape  of  the 
neck;  no  patches  are  found  on  the  elbows,  knees  and  scalp.  The 
eruption  is  more  or  less  polymorphous,  not  all  the  lesions  are 
psoriatif orm ;  finally,  there  are  coincident  glandular  swellings  or 
adenopathies,  mucous  patches,  etc.;  briefly,  signs  of  syphilis,  and  the 
Wasserniann  reaction  is  positive. 

The  tubercular  syphilides  of  tertiary  lues  may  be  abundantly 
squamous  and  psoriatif  orm.  However,  they  are  firm  to  the  touch, 
usually  circinate,  always  segregated,  regional,  not  very  numerous. 
Moreover,  healing  is  followed  by  cicatrices. 

ERYTHEMATO-SQUAMOUS  EPIDERMO-MYCOSES. 

Several  parasitic  cutaneous  diseases,  due  to  vegetable  parasites, 
may  assume  the  form  of  red  and  squamous  spots. 

This  is  rarely  the  case  in  pityriasis  versicolor;  its  spots  are  yellow- 
ish or  brownish;  exceptionally  they  may  be  of  a  pink  color.  It  is 
noteworthy  that  one  of  the  peculiarities  of  microsporon  furfur  is  that 
it  produces  practically  no  congestive  or  inflammatory  reaction. 

Erythrasma. — This  affection  on  the  contrary  often  leads  to  con- 
fusion, especially  with  the  pityriasiform  eczematides  in  large  patches. 
It  is  distinguished  by  the  dryness  of  its  scales,  by  its  localization, 
by  its  persistence,  by  the  almost  complete  absence  of  pruritus,  and 
especially  by  the  presence  of  the  microsporon  minutissimum  in 
large  numbers  in  the  epidermis  (p.  532). 

Trichophytosis  of  the  Smooth  Skin.— This  is  characterized  by  the 
generally  perfect  orbicularity  of  the  red  and  squamous  spots,  by 
their  relatively  rapid  and  regular  peripheral  development,  by  the 
rather  frequent  presence,  especially  on  their  borders,  of  vesicles  which 
have  earned  for  this  affection  the  name  of  herpes  circinatus  (p.  522). 

Epidermophytosis. — The  rapidly  extensive,  red  and  squamous 
spots,  with  polycyclic  contours,  bordered  by  small  vesicles  or  a 
scaly  margin,  which  develop  in  the  groin  and  in  the  large  cuta- 
neous folds,  constituting  the  eczema  marginatum  of  Ilebra,  are  due 
to  the  epidermophyton  inguinale;  the  microscope  readily  reveals 
the  mycelium  of  the  parasite  in  the  scales  (p.  524). 

Microsporosis.  Various  microsporons  may  vegetate  on  the 
hairless  skin;  the  spots  caused  by  them  are  of  irregular  form, 
indistinctly  outlined,  more  pityriasic  than  erythematous  and  very 
readily  curable  (p.  527). 

Favus  Cutaneus. — This  may  appear  without  "cups"  in  the  form 
of  red  and  squamous,  rarely  vesicular,  distinctly  outlined  and  fairly 
regular  rounded  spots  (favus  herpeticus) ;  the  achorion  is  abundantly 
represented  in  the  scales. 

Tropical  Epidermomycoses— These  are  discussed  elsewhere  in 
this  book  (p.  528). 


CHAPTER  VI. 
ERYTHRODERMAS. 

The  name  erythroderma  is  applied  to  a  very  extensive  or  general- 
ized, persistent  and  squamous  inflammatory  reddening  of  the  skin. 

The  symptom  of  extensive  and  persistent  redness  is  very  easily 
demonstrable;  but  as  it  occurs  under  very  different  pathological 
conditions,  its  significance  and  value  vary  to  a  high  degree. 

The  redness  of  erythroderma  is  inflammatory,  so  that  very  exten- 
sive vascular  nevi,  for  example,  do  not  belong  under  this  heading. 
The  vascular  congestion  is  sometimes  accompanied  by  a  certain 
degree  of  swelling  or  retraction  of  the  tissues ;  the  skin  feels  warm 
to  the  touch,  but  the  patients  frequently  complain  of  a  constant  cold 
sensation. 

The  redness  is  very  extensive;  however,  the  erythrodermas  are 
practically  limited  in  degree  to  the  chronic  erythemas  and  the 
erythemato-squamous  dermatoses. 

It  is  persistent.  The  meaning  of  this  word  is  somewhat  elastic; 
usually,  to  be  declared  as  erythrodermic,  the  duration  of  a  red 
eruption  must  exceed  seven  days. 

Finally,  and  especially,  the  erythrodermas  are  squamous  from  the 
start  or  after  a  few  days,  very  abundantly  or  scantily,  under  variable 
forms,  powdery,  furfuraceous,  lamellar  or  exfoliating,  etc.  The 
epithet  exfoliating  or  exfoliative  applies  to  a  considerable  number  of 
the  most  characteristic  types;  other  cases  have  been  designated 
under  the  name  of  pityriasis  rubra. 

The  term  "pityriasis"  according  to  Besnier,  is  a  simple  dermo- 
graphic  expression  specifying  a  particular  form  of  epidermic  des- 
quamation in  lamella?  as  fine  as  bran,  or  furfuraceous.  It  is  a 
traditional  designation,  not  indicative  of  any  relationship  between 
them,  for  cutaneous  affections  differing  as  widely  as  pityriasis 
simplex,  pityriasis  versicolor,  pityriasis  rosea  of  Gibert,  pityriasis 
rubra  pilaris.  The  common  denomination  "pityriasis  rubra" 
therefore  does  not  apply  to  all  erythrodermas  and  is  reserved  in 
this  book  for  the  variety  described  by  Hebra. 

The  symptom  of  erythroderma  is  met  with  under  four  different 
conditions:  (1)  As  a  constituent  of  peculiar  eruptions  developing 
on  the  healthy  skin;  these  are  the  Primary  Erythrodermas.  (2) 
Through  the  effect  of  generalization  of  one  of  the  dermatoses  with 


116  ERYTHRODERMAS 

red  and  squamous  spots,  described  in  Chapter  V;  for  this  group 
I  reserve  the  name  of  Erythrodermic  Dermatoses.  (3)  As  a  compli- 
cation of  a  preexisting  eruption;  these  arc  the  Secondary  Erythro- 
dermas. (4)  Finally,  there  occur  Congenital  Erythroderma*  and 
cases  developing  in  newborn  infants. 

I.  PRIMARY  ERYTHRODERMAS. 

Acute  forms  have  been  described,  lasting  a  few  weeks;  subacute 
forms,  lasting  several  months;  and  chronic  forms,  lasting  a  year  or 
longer. 

This  subdivision,  although  convenient  for  the  grouping  of  obser- 
vations, implies  neither  difference  nor  identity  of  character  among 
these  clinical  forms. 

.  1 .  Primary  Acute  Erythroderma. — This  is  a  generalized  erythema 
with  a  foliaceous  desquamation,  of  toxic  or  infectious  origin,  also 
known  under  the  name  of  Recurrent  desquamative  scarlatiniform 
erythema  ( Fereol  and  E.  Besnier)  and  Acute  benign  exfoliating 
dermatitis-  (Brocq). 

After  two  or  three  days  of  prodromata,  in  the  form  of  prostration, 
headache,  chills,  and  fever  of  38°  or  39°  [100°  to  102°]  the  eruption 
makes  its  appearance  as  a  red  pruritic  surface  in  the  large  folds  of 
the  trunk  and  the  limbs;  it  becomes  generalized  in  a  few  days,  the 
head  sometimes  escaping. 

Before  the  redness  disappears,  desquamation  begins  and  gradually 
extends;  it  is  locally  furfuraceous  but  more  apt  to  occur  in  large 
collodium-like  shreds  or  on  the  hands  and  feet,  in  the  form  of  an 
incomplete  glove  or  sandal  (Fig.  20).  The  skin  underneath  appears 
smooth,  sometimes  still  scaly,  or  oozing  in  the  folds.  The  mucous 
membranes  may  be  affected;  redness  of  the  conjunctiva3,  an  ery- 
thematous angina  and  desquamation  of  the  tongue  are  noted. 
The  genera]  condition  becomes  practically  normal  long  before  the 
end  of  the  cutaneous  disease,  which  lasts  about  three  weeks.  The 
nails  remain  marked  by  a  transverse  furrow;  loss  of  hair  is  incon- 
siderable. Relapses  are  frequent,  at  intervals  of  months  or  years, 
but  usually  dimmish  in  severity. 

The  causes  of  this  eruption  are  imperfectly  understood.  A  neces- 
sary predisposition  and  various  causative  factors  are  admitted. 
First  in  order  come  the  intoxications,  notably  mercury,  the  influence 
of  which  should  be  looked  for  in  all  its  forms:  internal,  external, 
medicinal  and  accidental;  picric  acid,  quinine,  chloral,  belladonna, 
opium,  may  also  be  responsible.  When  toxiderma  can  be  excluded, 
infections  are  to  be  thought  of,  such  as  gonorrhea,  malaria,  strepto- 
coccus infection,  etc 

The  differential  diagnosis  must  be  made  from  the  scarlatinoid 


PRIMARY  ERYTHRODERMAS 


117 


erythemas,  which  are  less  extensive,  more  transitory  and  less 
desquamative ;  and  especially  from  scarlet  fever  which  is  not  recur- 
rent, is  accompanied  by  angina  and  more  pronounced  general 
phenomena  and  has  a  more  belated  desquamation.  [The  most 
important  differential  feature  is  found  in  the  circumstance  that  the 
exfoliation  usually  begins  while  the  erythema  is  still  pronounced; 
but  a  diagnosis  is  often  impossible  and]  in  doubtful  cases  the  same 
prophylactic  measures  are  called  for  as  in  the  presence  of  scarlatina. 


Fig.  26. — Acute  primary  erythroderma  in  the  stage  of  desquamation  following 
ingestion  of  a  mixture  containing  opium  (Berge's  case,  Soc.  Med.  des  Hop.,  February 
22,  1907). 


B.  Primary  Subacute  Erythroderma. — This  probably  represents 
merely  a  more  prolonged  and  more  serious  form  of  the  preceding 
type;  it  is  also  known  as  generalized  exfoliative  or  exfoliating  derma- 
titis of  Wilson- Brocq. 

The  onset  is  the  same,  with  or  without  prodromata;  generaliza- 
tion is  complete,  somewhat  more  gradually  established;  the  folia- 
ceous  desquamation  is  so  active  that  handfuls  of  epidermal  shreds 
may  be  gathered  up  in  the  morning  from  the  patient's  bed.  The 
mucous  membranes  and  the  appendages  are  always  involved;  the 
nails  and  nearly  all  hairs  of  the  body  may  fall  out  toward  the  end 
of  the  third  to  fourth  week. 

The  tension  of  the  skin,  the  constant  sensation  of  cold,  the  loss  of1 
weight  notwithstanding  the  good  appetite,  the  diarrhea,  the  great 


118 


ERYTHRODERMAS 


diminution  in  nitrogen  excretion  and  the  hectic  fever  indicate  the 
gravity  of  the  disease.  Death  occurs  from  cachexia  or  as  the  result 
of  complications,  in  one-sixth  of  the  cases.  The  duration  is  from 
three  months  to  a  year. 

This  rather  uncommon  subacute  form  is  observed  in  adults, 
especially  in  inebriates  and  in  connection  with  some  form  of  intoxi- 
cation or  auto-intoxication.     Relapses  hardly  ever  occur. 

( '.  Primary  Chronic  Erythrodermias.  At  the  present  writing,  three 
types  can  be  differentiated. 


ititis  of  three  years'  standing,  in  a  man  aged 


1 .  The  Chronic  Form  of  the  Exfoliative  Dermatitis  of  Wilson-Brocq. — 
Under  this  heading  are  grouped  the  cases  analogous  to  primary 
subacute  erythroderma  but  lasting  several  years  (Fig.  27). 

2.  Pityriasis  Rubra  of  Hebra-Jadassohn.  The  erythema  begins  in 
various  regions,  especially  in  the  large  folds,  as  red  surface  lesions 
with  furfuraceous  scales,  without  infiltration  or  oozing.  The 
complete  generalization  takes  place  in  a  few  months,  at  most  two 
years;  chills  are  common  and  itching  is    variable. 


PRIMARY  ERYTHRODERMAS  119 

The  skin  gradually  becomes  thickened,  then  atrophied  and 
retracted  to  the  point  of  interfering  with  movements.  The  appen- 
dages fall  out.  Death  supervenes  at  the  end  of  a  few  years,  in 
a  state  of  general  marasmus  and  according  to  Jadassohn  almost 
invariably  through  tuberculosis.  Since  his  investigations  (1892) 
there  is  a  tendency  to  group  pityriasis  rubra  under  the  heading  of 
the  Tuberculides. 

Cases  of  partial  eruption  have  been  reported,  as  well  as  subacute 
benign  cases,  the  interpretation  of  which  is  doubtful. 

3.  Premycotic  and  Leukemic  Erythrodermas. —  In  male  adults,  the 
onset  of  an  erythroderma  has  been  observed  beginning  with  highly 
pruritic  red  spots,  becoming  universal,  scarlatinoid,  more  purplish 
in  the  folds  and  dependent  portions,  sometimes  with  depressed 
white  spots  scattered  here  and  there.  Desquamation  is  usually  very 
slight  or  it  may  be  dry  and  lamellar.  Febrile  attacks  may  occur. 
The  nails  usually  remain  intact,  but  the  hairs  fall  out  to  a  great 
extent. 

Three  constant  features  attract  attention :  a  frenzied  irrepressible 
pruritus,  causing  the  nails  to  become  worn  off,  edematous  thickening 
of  the  skin,  which  forms  ridges  toward  the  great  folds  and  generalized 
glandular  swelling. 

After  a  very  long  time,  up  to  ten  years  or  more,  small  cutaneous 
nodosities  may  make  their  appearance,  having  the  structure  of 
mycosis  fungoides  (p.  659) . 

This  premycotic  erythroderma,  pointed  out  by  Besnier  and 
Hallopeau,  may  present  prolonged  remissions;  it  may  also  lead  to 
death  from  cachexia  before  the  apperance  of  tumors. 

The  lymphoderma  pemiciosa  of  Kaposi  was  probably  an  erythro- 
derma of  this  kind,  which  became  complicated  by  leukemia  (p.  655). 

The  leukemic  erythroderma  studied  by  Audry,  Nicolau,  and  others, 
is  a  pathological  type  closely  related  to  the  preceding.  Desquama- 
tion is  perhaps  more  profuse  and  pruritus  less  severe ;  but  especially, 
in  addition  to  the  adenopathy,  there  is  hypertrophy  of  the  spleen 
and  a  relative  or  absolute  leukemia.  Sometimes,  the  appearance 
of  small  nodules  in  the  skin,  or  papillomatous  patches,  has  been 
noted.  Death  is  inevitable  and  may  supervene  in  less  than  two  years. 

All  cases  of  primary  chronic  erythroderma  necessitate,  from  the 
diagnostic  and  prognostic  point  of  view,  thorough  clinical  study  with 
careful  examination  of  the  viscera  and  glands,  complete  and  repeated 
examinations  of  the  blood  and  sections  of  the  skin  and  the  glands, 
for  histological  and  bacteriological  examination  as  well  as  animal 
inoculation.  Only  in  this  way  can  we  hope  to  determine  the  rela- 
tions of  pityriasis  rubra  and  mycosis  fungoides  with  the  leukemias, 
pseudoleukemias,  tuberculosis,  etc. 


120  ERYTHRODERMAS 

n.  ERYTHRODERMIC  DERMATOSES. 

Sonic  of  the  great  dermatoses  may  become  erythrodermic  through 
generalization  in  the  course  of  their  evolution.  In  these  cases,  the 
characteristics  of  the  eruption  persist,  only  modified  by  the  extension 
it  lias  undergone. 

Generalized  Eczema.  -Generalized  eczema  proceeds  in  successive 
relays,  invading  new  territories  and  becomes  permanently  estab- 
lished if  the  conditions  of  eczematosis  exist  in  the  patient;  but  it 
rarely  becomes  universal.  Even  in  these  cases  it  retains  its  tendency 
to  recrudescences,  paroxysms,  oozing,  to  a  reddened  appearance  and 
severe  itching.  The  mucous  membranes  remain  intact  and  the 
appendages  are  only  gradually  affected.  The  general  condition  is 
far  from  being  as  seriously  affected  as  in  the  cases  of  true  erythro- 
derma, whether  primary  or  secondary. 

The  principal  difficulty  is  the  recognition  of  the  nature  of  this 
eczema,  whether  it  is  primary,  or  secondary  to  a  prurigo,  for  instance, 
;u id  on  the  other  hand  to  discover  the  nutritional  disturbances, 
internal  suppuration  or  visceral  lesion  of  which  it  is  often  a  mani- 
festation, such  as  nephritis,  cancer,  etc.  The  treatment  is  not  very 
effective  and  must  be  very  cautiously  handled. 

In  generalized  eczematide—  pityriasis  rubra  seborrhceica  of  Unna, 
or  malignant  exfoliating  form  of  seborrheal  eczema — the  eruption 
extends  little  by  little  but  is  rarely  universal.  The  eruptive  areas 
or  widely  invaded  regions  are  sometimes  red  and  dry,  covered  with 
pityriasis-  fatty  scales,  sometimes  oozing  and  covered  with  yellowish 
scaly,  not  very  adherent  crusts,  the  contours  are  rounded  or 
polycyclic  (see  Fig.  18,  abdominal  region);  in  the  folds  and  under 
i  he  thick  crusts,  serous  or  purulent  oozing  is  present  in  all  cases. 

It  is  often  difficult,  until  a  few  days  or  weeks  of  treatment  have 
elapsed,  to  distinguish  between  a  generalized  eczematide,  a  primary 
or  secondary  eczema  and  an  eczematized  psoriasis.  The  rounded 
crusts  may  even  suggest  pemphigus.  The  general  condition  usually 
remains  favorable.  The  prognosis  is  less  gloomy  than  that  of  the 
other  generalized  dermatoses  and  especially  that  of  exfoliating 
berpetide  (p.  122).  It  depends  upon  the  degree  of  toleration  of  the 
skin  for  the  topical  reducing  agents  which  must  here  be  employed 
with  moderation. 

Psoriasis  universalis  may  finally  become  absolute  and  total;  the 
redness  is  uniform  from  head  to  foot;  the  desquamation  loses  its 
stratified  and  micaceous  character,  except  at  the  seats  of  pre- 
dilection; neither  oozing,  nor  crusts,  nor  pruritus  is  present.  The 
hairs  of  the  seal])  and  body  become  scanty;  the  nails  are  striated 
and  ridged.     Arthropathies  may  develop. 

The  course,   without   paroxysms,    is   of   an   absolutely   chronic 


SECONDARY  ERYTHRODERMAS  121 

character.  Treatment  often  remains  completely  ineffective ;  although 
I  have  obtained  nearly  complete  but  always  temporary  cures  by 
means  of  mercurial  injections,  using  calomel  or  the  yellow  oxide. 
The  arsenobenzols  might  be  given  a  trial. 

Pityriasis  rubra  pilaris  may  exceptionally,  at  the  onset  or  in 
consequence  of  its  progressive  extension,  present  an  erythrodermic 
appearance.  But  healthy  skin  areas  can  always  be  demonstrated, 
in  distinctly  outlined,  sometimes  angular  islands  as  well  as  peripilar 
cones  on  the  borders  of  the  surface  lesions  or  at  the  points  of  election. 
The  desquamation  is  plaster-like  and  adherent. 

Acute  lichen  planus,  sometimes  spreads  over  large  surfaces  and 
may  assume  an  erythrodermic  appearance;  this  abnormal  exten- 
sion is  usually  initial  and  rapidly  retrogressive.  It  soon  becomes 
possible  to  discover  the  characteristic  papules,  if  necessary  with  the 
assistance  of  a  lens  on  the  red  surfaces  themselves  or  at  their  borders. 

Pemphigus  foliaceus  occasionally  presents  to  a  high  degree  the 
clinical  appearance  of  an  abundantly  exfoliating  erythroderma. 
The  disease  has  generally  passed  at  the  onset  through  a  stage  of 
bullous  eruption  and  sometimes  bullous  lesions  can  be  found 
around  the  erythrodermic  areas.  The  exfoliation  of  pemphigus 
foliaceus  is  noteworthy  for  the  moist  or  even  oozing  condition  of  the 
tissues  underneath  the  scales. 

Equine  scabies  is  a  very  rare  disease  which  may  appear  under  the 
guise  of  erythroderma,  as  illustrated  by  the  case  of  Besnier's  and  a 
personal  observation  of  my  own.  The  redness  is  universal,  involving 
even  the  face  and  the  scalp;  the  crusted  or  powdery  scales  predomin- 
ate on  the  hands  and  feet;  itching  is  not  excessive.  No  burrows 
can  be  detected;  but  even  the  smallest  scale  is  seen  under  the 
microscope  to  teem  with  the  parasite  (sarcoptes)  in  all  its  stages. 

m.  SECONDARY  ERYTHRODERMAS. 

.  Generalization,  as  has  been  seen,  leads  to  the  so-called  "  erythro- 
dermic" appearance  in  the  great  dermatoses  which  have  just  been 
briefly  reviewed.  On  the  other  hand,  their  course  may  be  tempor- 
arily arrested  by,  or  it  may  terminate  in  a  very  extensive  or  even 
universal  exfoliating  dermatitis;  this  marks  and  transforms  the 
characteristics  of  the  first  eruption  and  seems  to  take  its  place, 
reproducing  the  aspect  and  behavior  of  a  primary  erythroderma. 

In  the  first  case,  there  has  been  an  extension  with  more  or  less 
complete  preservation  of  the  characteristics  belonging  to  the  first 
eruption;  the  second  case,  where  there  is  unification  of  the  patho- 
logical picture,  was  interpreted  by  the  older  authors  as  a  transfor- 
mation, whereas  modern  writers  are  inclined  to  see  in  it  the  effect  of 
a  complication. 


122  ERYTHRODERMAS 

It  is  readily  understood  that  an  investigation  of  the  patient's 
antecedents  and  preliminary  condition  is  usually  required  in  order 
to  establish  the  fact  that  the  erythroderma  is  really  secondary  and 
the  nature  of  the  dermatosis  on  the  soil  of  which  it  has  developed. 

The  secondary  erythrodermas  manifest  themselves  under  two 
forms,  ordinarily  designated  by  the  traditional  names  of  benign 
herpetide  and  malignant  herpetide. 

Benign  Form  (episodic  erythrodermas  of  Besnier). — The 
erythrodermie  complication  may  be  partial,  regional  or  very  exten- 
sive; rarely  is  it  total;  it  is  always  transitory,  lasting  a  few  days  to  a 
few  weeks.  There  are  valid  reasons  for  ascribing  it  to  the  inoppor- 
tune or  badly  tolerated  intervention  of  an  external  medicinal  agent, 
such  as  a  mercurial  preparation,  chrysarobin,  picric  acid,  etc.,  or  of 
some  internal  medication.    Relapses  are  extremely  liable  to  occur. 

Malignant  Form  (exfoliative  herpetide  of  Bazin,  chronic  malig- 
nant exfoliative  dermatitis  of  Vidal  and  Leloir).  —  By  Bazin, 
who  described  it,  exfoliative  herpetide  was  interpreted  as  the 
common  outcome  of  certain  eczemas,  psoriasis,  pityriasis;  super- 
vening by  imperceptible  transition  and  representing  a  sort  of  cachexia 
of  the  skin,  comparable  to  asystoly  in  heart  disease. 

The  symptoms  are  those  of  the  subacute  form  of  primary  erythro- 
derma, but  with  less  fever;  there  is,  however,  well-marked  general 
exhaustion  and  marasmus.  The  elimination  of  urea  in  the  urine, 
always  greatly  diminished,  may  be  reduced  to  10  or  even  4  grams 
per  day;  on  the  other  hand,  up  to  10  grams  of  urea  have  been  found 
in  the  daily  scales. 

The  prognosis  is  fatal  although  more  or  less  prolonged  remissions 
have  been  observed. 

There  is  a  tendency  to  attribute  this  "  malignant  herpetide"  to  a 
toxic,  infectious  or  autotoxic  complication  of  the  same  character 
as  that  which  gives  rise  to  the  primary  erythrodermas. 

IV.  CONGENITAL  ERYTHRODERMAS  AND  ERYTHRODERMAS 
OF  THE  NEWBORN. 

In  little  children,  various  types  of  congenital  or  acquired,  tempo- 
rary or  persistent  exfoliative  erythrodermas  have  been  observed. 
The  following  cases  must  be  distinguished : 

1 .  Lamellar  Desquamation  in  the  Newborn. — This  represents  an 
exaggeration  of  the  phenomenon  of  physiological  desquamation 
seen  in  many  newborn  infants  and  consists  of  desiccation  and 
splitting  of  the  epidermis  in  the  first  days  of  life,  followed  by  the 
shedding  of  this  epidermis,  furfuraceous  or  in  shreds,  from  the  third 
to  fifth  day  up  to  the  thirtieth  or  sixtieth,  according  to  Parrot. 

In  rare  cases,  such  as  that  observed  by  Grass  and  Torok  (1S95), 


ERYTHRODERMAS  OF  THE  NEWBORN 


123 


the  child  is  bom  with  a  sort  of  supra-epithelial  collodium-like  layer 
(epitrichium) ;  this  splits  after  the  first  hour  and  in  a  few  days 
becomes  detached  in  the  form  of  large  shreds ;  the  skin  then  becomes 
normal  again. 

2.  Exfoliative  Dermatitis  of  Nurslings. — Described  by  Ritter  von 
Rittersheim  (1878)  begins  during  the  first  to  fifth  week  of  life,  around 
the  mouth  or,  more  rarely,  in  other  parts  of  the  body;  it  becomes 
rapidly  generalized  over  the  entire  integument  and  finally  extends 
to  the  extremities.  The  skin  is  of  a  purplish-red  color  and  is  des- 
quamated in  large  dry  shreds.  Bulla?  have  sometimes  been  observed. 
Certain  authors  believe  that  this  affection  is  related  to  epidemic 
pemphigus.  As  a  rule,  the  disease  is  febrile  and  in  one-half  of  the 
cases  it  leads  to  death,  often  within  a  week. 


Jf 

...  j      111 

wL 

.. 

^^^^^          .JrtM 

'■■'  •    .  *         ■    ".' 

\  JssHaaHBM 

Fig.  28. — Erythroderma  in  a  newborn  infant  (generalized  eczematide.) 


3.  Generalized  Dermatoses. — Various  generalized  dermatoses,  in- 
cluding medicinal,  mercurial  and  other  eruptions,  are  encountered 
in  children. 

I  have  published  a  case  of  seborrheal  eczema  or  eczematide  in  an 


1 24  ERYTHRODERMAS 

otherwise  healthy  child  of  five  weeks  (  Fig.  28);  onset  at  the  ear. 
almost  total  generalization  in  nine  days;  scarlatinoid  redness  with 
dry  scales  or  greasy  crusts,  in  different  localities;  recovery  in 
three  weeks. 

Desquamative  Erythroderma  of  Nurslings,  described  l>y  ('.  Leiner 
in  1907,  is  a  morphologically  analogous  morbid  type.  He  was 
enabled  to  observe  43  cases,  usually  beginning  on  the  scalp, 
with  1")  deaths.  Beck's  record  of  16  personal  cases,  in  which  the 
disease  usually  began  on  the  buttocks,  confirms  the  observation 
that  this  grave  eruption,  which  seems  to  be  of  toxic  character,  is 
peculiar  to  breast-fed  children  suffering  from  enteritis.  A  change  of 
alimentation  is  urgently  required. 

4.  Diffuse  Congenital  Hyperkeratosis. — Also  known  as  congenital 
or  fetal  ichthyosis,  or  ichthyosis  sebacea  (Kaposi),  is  a  cutaneous 
malformation  of  which  several  degrees  are  known: 

The  severe  type  (diffuse  congenital  malignant  keratoma)  [harlequin 
fetus]  \>  incompatible  with  life.  The  infant,  born  at  term  or  pre- 
maturely, presents  a  dreadful  appearance;  its  entire  skin  is  red 
and  tense,  as  if  too  tight,  fissured,  covered  with  large  yellowish 
layers  or  crusts  several  millimeters  thick,  apparently  resulting  from 
the  desiccation  of  a  sebaceous  coating.  The  face  is  formless;  move- 
ments of  the  limbs  are  almost  impossible;  the  child  is  unable  to 
suckle  and  promptly  succumbs  to  cold. 

The  benign  type  (generalized  ichthyosiform  hyperkeratosis)  is  not 
■fatal;  it  is  usually  confused  with  ichthyosis.  It  will  be  discovered 
in  the  chapter  on  the  Keratoses  (p.  203). 

Pathological  Anatomy  of  the  Erythrodermas. — The  lesions  of  all 
erythrodermas  are  associated  with  vascular  congestion,  a  variable 
cellular  infiltration  in  the  papillary  body,  with  more  or  less  edema 
and  pigmentation  and  corneal  exfoliation,  the  mechanism  of  which 
usually  remains  obscure. 

Reliable  histological  investigations  are  not  numerous  and  have 
yielded  divergent  results  in  forms  bearing  the  same  label.  At  the 
present  writing  a  differential  histological  diagnosis  between  the 
various  types  is  out  of  the  question.  The  following  are  the  few 
available  data  on  this  subject: 

In  the  primary  subacute  erythrodermas  there  is  claimed  to  be 
parakeratosis,  intrapapillary  infiltration  with  enlargement  of  the 
papillae.  Central,  ganglionic  and  peripheral  nervous  lesions  have 
been  described  by  Mario  Oro. 

In  the  pityriasis  rubra  of  Hebra  the  papillary  body,  at  first 
infiltrated,  later  on  undergoes  atrophic  changes;  the  glands  and 
follicles  disappear;  the  stratum  granulosum  is  diminished  or  absent. 
In  a  very  remarkable  case  Brunsgaard  found  in  sections  of  the  skin 
typical  tubercles  with  giant  cells  and  Koch's  bacilli.    It  had  already 


ERYTHRODERMAS  OF  THE  NEWBORN 


125 


been  shown  by  Jadassohn  that  in  autopsies  on  cases  of  pityriasis 
rubra,  tuberculosis  was  found  in  various  organs  in  seven  out  of 
eight  cases. 

Premycotic  erythroderma  represents  the  most  distinctive  ana- 
tomical type.  The  illustration  gives  a  fairly  accurate  idea  of  the 
condition  (Fig.  29). 


Fig.  29. — Histology  of  premycotic  erythroderma.  The  dominant  lesion  con- 
sists of  a  very  dense  cellular  infiltration  (F) ,  occupying  the  papillary  body  and 
having  a  sharp  lower  boundary;  it  is  composed  of  lymphoid  cells  arranged  in  an 
adenoid  network.  The  afferent  vessels  of  the  chorion  (G)  are  surrounded  by  cellular 
cuffs.  The  papillse  (E)  are  enlarged  and  elongated.  The  interpapillary  buds  (A) 
are  drawn  out  and  often  bifid.  The  horny  layer  (B)  is  thick  and  desquamating. 
Parakeratosis  is  noted  in  places  (C).  In  the  rete  may  be  seen  minute  cellular  nests 
(£))  filled  with  lymphocytes;  those  are  inconstant,  but  possess  great  diagnostic  value, 
being  specific  of  mycosis  fungoides.    X  65. 


In  the  malignant  exfoliative  herpetides  there  exist  parakeratosis, 
according  to  Leloir,  and  a  destructive  change  of  the  connective- 
tissue  fibers,  especially  around  the  vessels,  with  preservation  of  the 
elastic  fibers.  These  lesions,  which  were  reported  as  characteristic, 
could  not  be  confirmed  by  Mario  Oro. 

The  generalized  dermatoses  preserve  the  histological  lesions 
peculiar  to  them,  although  with  some  modifications. 

Treatment  of  the  Erythrodermas. — The  most  essential  requirement 
is  to  ascertain  with  great  care  the  possible  cause  of  the  erythroderma. 
When  there  is  reason  to  suspect  an  intoxication,  or  some  external 
agent,  this  injurious  factor  must,  of  course,  be  removed.  An 
existing  auto-intoxication  should  be  controlled  by  dietetic  measures, 
free  ingestion  of  water,  enteroclysis,  injections  of  glucose  or  other 
sera,  together  with  general  hygiene.     With  special  reference  to 


126  ERYTHRODERMAS 

mycosis  fungoides  and  the  leukemias  and  pseudoleukemias,  radio- 
therapy  is  known  to  furnish  a  valuable  method,  if  not  for  a  cure  at 
least  for  improvement  and  retardation  of  the  course  of  the  disease. 

Local  Treatment  must  aim  especially  at  non  nocere.  It  comprises, 
depending  on  the  case,  prolonged  or  even  permanent  emollient 
baths,  such  as  were  formerly  given  abroad;  moist  aseptic  dressings, 
or  applications  of  oil  and  lime-water  liniment,  which  are  very 
troublesome  to  handle  but  afford  a  marked  relief  for  the  pruritus; 
finally,  wrapping  in  cotton.  It  is  often  useful  to  cover  the  patient 
[thickly  and  continuously]  with  a  bland  powder  between  two  sheets 
and  to  apply  lotions  only  here  and  there  or  partial  inunctions 
with  a  paste  or  a  cream.  Caoutchouc  must  be  very  cautiously 
employed;  it  will  blanch  certain  erythrodermas,  it  is  true,  but 
seems  to  be  capable  of  inducing  very  dangerous  repercussions. 

All  these  topical  agents  are  merely  palliatives,  aiming  at  the 
relief  of  the  patient  and  the  prevention  of  complications.  They 
represent  simply  a  marked  form  of  expectant  treatment. 


CHAPTER  VII. 
PAPULES  AND  PAPULAR  DERMATOSES. 

The  eruptive  lesions  described  as  papules  are  small  solid  ele- 
vations which  subside  spontaneously.  The  terms  of  this  definition 
may  be  stated  with  greater  precision,  as  follows: 

The  papules  are  circumscribed  elevations  of  small  dimensions; 
they  have  the  size  of  a  pin-head,  a  lentil  or  at  most  a  large  pea;  they 
are  always  protuberant,  but  to  a  very  variable  degree. 

The  papules  are  solid,  which  means  that  they  do  not  contain  an 
effused  fluid;  it  is  sometimes  necessary  to  prick  them  with  a  needle 
in  order  to  ascertain  this  fact.  Finally,  papules  do  not  persist  indefi- 
nitely, a  feature  which  distinguishes  them  from  small  tumors  of 
the  same  appearance;  they  disappear  of  their  own  accord,  without 
leaving  a  scar,  which  differentiates  them  from  tubercles;  this  is 
expressed  in  the  statement  that  they  undergo  spontaneous  resolution. 

Many  papules  develop  exclusively  at  the  site  of  the  hair- 
follicles;  these  follicular  papules  will  be  discussed  with  the  folliculoses 
(XIX). 

The  papular  prominence  may  become  associated  with  various 
processes,  for  instance  hemorrhage  {papular  purpura);  vesicle  form- 
ation in  certain  eczemas  (papulo-vesicular  eczema),  and  formation 
of  pustules  (papulo-necrotic  tuberculides),  etc. 

Very  large  papules  are  sometimes  designated  as  papulo-tubercles. 

It  sometimes  happens  that  an  infiltration  similar  to  that  which 
constitutes  the  papules,  instead  of  being  closely  restricted  to  a  very 
small  surface,  is  spread  out  on  the  contrary  in  coin-shaped  (num- 
mular) discs  or  in  patches  and  becomes  superimposed  on  an  erythe- 
matous, erythemato-squamous,  etc.,  process.  In  such  cases,  although 
these  expressions  are  not,  strictly  speaking,  correct,  it  is  customary 
to  employ  the  terms  of  papular  plaques  or  patches. 

Anatomical  Characteristics  of  the  Papules. — The  eruptive  lesion 
known  as  a  papule  may  be  produced  through  different  pathological 
processes.  According  as  they  affect  chiefly  the  epidermis  or  the 
derma  or  the  two  tissues  alike,  a  distinction  is  made  between 
epidermic  papules,  dermic  papules  and  mixed  papules. 

Epidermic  Papules.— Epidermic  papules  are  most  typically 
represented  by  the  flat  warts  (Fig.  30) .  In  these,  all  the  layers  of  the 
epidermis  are  hypertrophied,  the  mucous  body  (acanthosis)  as  well 


12S 


PAPULES  AND  PAPULAR  DERMATOSES 


as  the  granular  layer  (granulosis)  and  the  horny  layer  (keratosis). 
The  papillae  are  elongated  (papillomatosis)  up  to  ten  times  their 
normal  height.  There  is  very  little  edematous  or  cellular  infiltra- 
tion in  the  derma. 


y  u'v 


■'■-r~'-.^  '- 


.  KiRMAHSHI. 


Fig.   30. — Section  of  an  epidermic  papule.     Flat  wart  of  the  face.    A,  keratosis; 
B,  granulosis;  C,  acanthosis;  D,  papillomatosis.      X  33. 

Iii  the  papule  of  prurigo,  the  rete  mucosum  especially  is  hyper- 
trophied,  being  three  to  four  times  thicker  than  normal;  the  con- 
dition of  the  horny  layer  and  of  the  papillte  is  extremely  variable. 

Dermic  Papules. — Dermic  papules  are  of  two  kinds  depending 
on  whether  the  substance  which  causes  the  prominence  is  an 
edematous  fluid  or  an  inflammatory  cellular  infiltrate. 


f^f^N 


i-  -&.; 


Fig.  31. — Section  of  a  dermic  papule.     Lenticular  papular  syphilide.      X  25. 


The  edematous  papule  is  seen  in  urticaria  and  papular  erythema; 
the  local  congestion  and  exudation  of  plasma  between  the  meshes  of 
the  papillary  body  disappear  in  part,  at  the  same  time  as  the  blood- 
pressure,  in  the  cadaver  and  in  excised  segments;  hardening  of  the 


MIXED  PAPULES  129 

specimen  in  alcohol  entirely  obliterates  the  lesions.  When  the  eryth- 
ema-papule is  not  purely  urticarial,  but  more  or  less  infiltrated,  it 
is  found  to  contain  perivascular  collections  composed  mainly  of 
leukocytes. 

The  most  typical  example  of  infiltrated  papules  is  furnished  by 
lenticular  papular  sypkilides  (Fig.  31).  The  epidermis  here  is 
passively  distended,  thinned,  sometimes  with  corneal  exfoliation. 
The  papillary  body  and  the  upper  layer  of  the  corium  are  the  seat  of 
a  very  abundant  compact  infiltration  of  cells,  among  which  plasma 
cells  predominate  with  a  few  giant  cells ;  at  the  periphery  of  the  main 
focus  the  infiltration  consists  of  perivascular  cuffs  of  plasmocytes. 

The  papule  of  lichen  scrofulosorum  is  also  essentially  dermic; 
it  is  found  to  contain  an  infiltration  of  cells  of  various  kinds,  lym- 
phoid, epithelioid  and  giant  cells,  often  arranged  as  tubercles,  either 
in  the  papillary  body  or  in  the  vicinity  of  pilo-sebaceous  follicles. 

Mixed  Papules. — In  the  mixed  papules  there  exist  combined 
epidermic  and  dermic  lesions.  The  papule  of  lichen  planus,  which 
belongs  to  this  type,  consists  of  acanthosis,  with  more  or  less 
keratosis  and  a  limited  infiltration  of  the  papillary  body;  the 
granular  layer  is  hypertrophied  here  and  there. 

The  papule  of  strophulus  has  a  thickened  epidermis  with  localized 
spongiosis  and  an  edematous  infiltrated  dermic  base. 

Clinical  Characteristics  of  the  Papules. — A  trained  observer  will 
have  no  special  difficulty  in  the  clinical  distinction  of  the  different 
varieties  of  papules.  The  epidermic  hypertrophy  manifests  itself  as  a 
superficial,  dry  and  hard,  often  yellowish  prominence,  which  is  in  no 
way  reducible  on  pressure. 

Edematous  papules  are  pinkish-white,  tense  but  compressible; 
they  can  be  reduced  by  pressure  with  the  finger-nail,  but  resume 
their  shape  after  a  few  minutes. 

The  dermic  cellular  infiltration  produces  a  pink  or  red  papule 
which  is  more  profoundly  indurated,  resistant  and  elastic. 

The  condition  of  the  horny  layer  at  the  surface  of  the  papule  is  of 
great  importance,  depending  on  the  existing  dermatosis;  it  may  be 
thickened  or  stretched,  desquamating  in  more  or  less  friable  and 
abundant  lamellse  or  transformed  into  scales,  crusts,  and  so  forth. 

The  differential  diagnosis  of  papules  in  general  is  based  upon 
their  objective  appearance  and  their  course.  In  the  first  place, 
care  must  be  taken  not  to  confuse  them  with  vesicles  or  pustules, 
which  contain  a  fluid;  with  the  tubercles  of  syphilis,  leprosy, 
lupus  or  with  tuberculides,  which  leave  cicatrices;  finally,  with 
tumors  of  small  dimensions,  which  are  indefinitely  persistent 
or  progressive,  such  as:  various  nevi,  sebaceous  adenomas  and 
hidradenomas,  small  cysts,  circumscribed  keratomas,  epitheliomas, 
tumors  of  molluscum  contagiosum,  etc. 


130  PAPULES  AND  PAPULAR  DERMATOSES 

In  some  cases  a  careful  examination,  pressure  under  a  glass  slide 
(vitropressure),  expression  of  the  contents,  puncture  with  a  needle 
or  sometimes  even  the  removal  and  examination  of  a  piece  of 
tissue  for  biopsy  may  be  necessary. 

The  following  syndromes  will  be  described  in  this  chapter: 
Juvenile  flat  warts,  which  represent  a  special  clinical  variety  of 
common  warts.  Lichen  planus,  with  typical  papular  eruption,  as 
well  as  its  atypical  varieties,  which  should  be  studied  in  this  connec- 
tion, in  spite  of  the  irregular  features  assumed  by  the  eruption;  the 
papules  of  prurigo,  as  eruptive  lesions,  the  disease  as  such  being 
discussed  in  a  separate  chapter  (XXIV);  typical  papular  syphil- 
itic*; finally,  the  papular  form  of  tuberculides  known  as  lichen 
scrofulosorum. 

JUVENILE  FLAT  WARTS. 

The  warts  designated  under  this  name  appear  as  an  eruption 
of  small  epidermic  papules,  not  more  than  3  mm.  in  diameter,  flat- 
tened and  barely  protuberant;  they  have  rounded  or  irregularly 
polygonal  contours,  are  sharply  circumscribed,  have  the  color  of  the 
normal  skin  or  show  a  yellowish,  grayish  or  brownish  tint;  their 
surface  is  finely  puckered  or  slightly  scaly;  they  cause  no  itching. 

The  warts  are  met  with  especially  on  the  face,  more  particularly 
the  cheeks,  temples,  forehead  and  chin,  from  a  few  up  to  several 
hundred  in  number.  They  may  also  occupy  the  back  of  the  hands, 
associated  or  not  with  common  warts,  but  are  less  frequent  on  the 
forearms.  I  have  counted  over  1500  on  a  young  girl  whose  face, 
neck  and  even  chest  were  dotted  with  them. 

These  warts  undoubtedly  result  from  auto-inoculation  or  through 
transmission  from  other  flat  warts,  probably  also  from  common 
warts  existing  on  the  patient  himself  or  in  persons  of  his  environ- 
ment. Children,  young  girls  and  young  women  are  particularly 
susceptible.     In  men,  they  may  be  spread  by  means  of  the  razor. 

After  having  multiplied  and  persisted  for  months  or  sometimes 
years,  these  flat  warts  finally  disappear  spontaneously  without  leav- 
ing ;i  trace. 

The  treatment  must  therefore  aim  especially  at  avoiding  produc- 
tion of  scars.  Caustic  agents  must  not  be  used.  Tainting  with  an 
exfoliating  mixture  is  usually  prescribed  (Therapeutic  Notes,  Sec- 
tion 5).  Radiotherapy  will  cure  flat  warts  with  astonishing  rapidity; 
a  single  session,  with  moderate  dosage,  is  often  sufficient.  High- 
frequency  sparks  are  likewise  very  successful.  Jadassohn  empha- 
sizes the  efficacy  of  arsenic  treatment.  Suggestion  probably  plays 
a  part  in  certain  cures  and  the  same  remark  is  true  for  common 
warts. 


LICHEN  PLANUS 


131 


LICHEN  PLANUS. 

The  term  lichen  was  applied  by  Willan  (and  since  his  time) 
to  dermatoses  of  different  character.  At  the  present  time,  the 
existence  of  a  lichen  "  genus"  comprising  several  species  is  no  longer 
admissible.  With  the  simple  use  of  the  term  lichen,  we  now  refer 
to  the  great  and  well  defined  dermatosis — also  known  as  lichen 
planus,  lichen  ruber  planus  or  Wilson's  lichen — to  be  described  in 
the  following. 

The  expressions:  lichen  simplex,  lichen  obtusus,  lichen  corneus, 
lichen  scrofulosorum,  will  be  defined  further  on. 


Fig.  32. — Lichen  planus  of  the  wrist  and  the  palm  of  the  hand. 

Symptoms. — The  eruptive  lesion  of  lichen  planus  is  a  typical 
papule,  of  the  average  dimensions  of  a  pin-head,  of  polygonal  flat- 
tened form,  sometimes  depressed  or  umbilicated;  its  surface  is 
smooth  and  shining;  its  consistence  is  dry  and  firm;  its  color  varies 
from  a  yellowish  pink,  which  is  the  most  common,  to  a  dusky  or 
purplish  red;  sometimes  the  color  does  not  differ  from  that  of  the 
normal  skin. 

These  sufficiently  characteristic  features  are  often  combined  with 
another,  which  is  pathognomonic :  the  presence  of  white  or  grayish 
opaline  streaks  and  dots  marking  on  the  surface  of  the  papules  a 
network  or  nodular  arborizations  or  stars  on  a  pink  background. 
The  "sign  of  the  net,"  the  importance  of  which  was  emphasized  by 
L,  Wickham,  is  distinctly  visible  only  on  well-developed  papules, 


i:;: 


PAPULES  AST)  PAPULAR   DERMATOSES 


which  may  be  isolated  or  grouped  in  patches;  in  order  to  demon- 
strate the  net,  it  is  advisable  to  moisten  the  papules  with  water, 
or  paraffin  oil,  or  better  with  anilin  oil  which  renders  the  horny 
layers  transparent. 

The  incipient  papules  are  punctiform,  pink  and  glistening;  they 
enlarge  in  a  few  days  or  weeks.  Full-grown  papules  may  remain 
isolated  in  discrete  eruptions,  but  almost  invariably  they  multiply 
and  become  confluent  in  plaques  of  very  variable  extent  and  round, 
oval,  or  irregular  shape,  usually  thicker  on  the  borders  than  in  the 
middle,  of  a  dusky  red  or  brownish  color. 

Their  surface  is  covered  with  fine,  very  adherent,  often  scarcely 
visible  scales,  but  the  finger-nail  passing  over  the  surface  leaves  a 
scaly  line.  Horny  granules  are  sometimes  seen.  The  papules  con- 
stituting  the  patch  are  sometimes  recognizable,  especially  on  the 
borders.  Extensive  plaques  and  patches,  when  there  is  complete 
confluence,  are  cut  in  squares  by  lozenge-shaped  or  polygonal 
designs  Inning  a  smooth  and  glistening  surface,  producing  a  mosaic 
appearance.  On  the  surrounding  -kin  isolated  papules  and  other 
groupings  may  be  seen. 


Fig.  33 


It  is  the  rule  for  lichen  planus,  especially  when  the  eruption  has 
existed  for  ;i  few  weeks,  to  be  accompanied  by  dyschromia.  The 
papules  and  patches  become  more  or  less  pigmented  or  become 
surrounded  by  ;i  pigmented  areola;  sometimes,  the  center  is  color- 
less while  the  circumference  is  hyperpigmented,  brownish  or 
blackish.  Tin-  symptom  may  be  absent.  The  coexistence  of 
genuine  vitiligo  is  not  very  rare. 

The  most  common  localization  of  the  eruption  is  the  anterior 
surface  of  the  wrists,  the  forearms  and  the  legs;  but  it  is  also 
observed  on  the  flanks,  the  lumbar  region,  the  genital  organs,  the 
buccal  mucosa,  the  neck,  the  palmar  and  plantar  regions,  rarely  on 
the  face  and  very  exceptionally  on  the  hairy  scalp.  The  eruption 
may  be  almost  universal, 


LICHEN  PLANUS  133 

Pruritus  may  be  altogether  absent,  often  it  is  slight  and  inter- 
mittent; sometimes,  very  severe  and  even  excessive  to  the  point  of 
interfering  with  rest.  It  may  therefore  be  said  that  patients  suffer- 
ing from  lichen  planus  scratch  themselves,  "a  little,  a  great  deal, 
violently,  or  not  at  all." 

Scratching  is  undoubtedly  responsible  for  the  diffuse  lichenization 
which  frequently  accompanies  the  typical  eruption,  sometimes 
concealing  it. 

Varieties. — There  exist  several  varieties  of  lichen  planus  char- 
acterized by  a  particular  form  of  the  eruptive  lesions,  or  of  their 
arrangement,  by  certain  localizations,  or  by  an  abnormal  course 
of  the  disease. 

The  papules  of  lichen  planus  may  assume  the  form  of  very 
regular  rings,  from  6  to  8  mm.  in  diameter,  with  a  pigmented  center; 
this  form  is  encountered  especially  on  the  genital  regions,  on  the 
internal  surface  of  the  arms,  on  the  flanks  and  near  the  articular 
folds.  The  existence  of  a  few  rings  in  a  typical  eruption  is  not 
uncommon;  they  may  predominate  in  a  given  region,  constituting 
lichen  annulatus. 

Sometimes,  in  the  same  regions,  the  papules  are  grouped  in  circles, 
with  centrifugal  extension,  in  gyrate  or  arabesque  patterns;  this 
condition  is  described  as  lichen  marginatus  sen  serpiginosus. 

There  also  occurs  an  arrangement  of  the  papules  in  linear  streaks, 
apparently  referable  to  streaks  from  scratching:  lichen  striatus;  or 
following  the  course  of  a  nerve  after  the  manner  of  herpes  zoster 
or  a  linear  nevus:  lichen  zoniformis. 

In  certain  cases  of  lichen  planus  taking  an  acute  or  subacute 
course,  the  typical  lesions  may  be  associated  with  a  few  acuminate 
papules.  It  might  be  conceded  that  this  partial  and  occasional 
irregularity  is  entitled  to  the  special  name  of  lichen  acuminatus. 
However,  at  the  International  Congress  held  in  Paris  in  1889,  the 
foreign  authors  present  admitted  that  the  majority  of  the  cases, 
which  with  Kaposi  they  called  lichen  ruber  acuminatus,  actually 
belonged  to  pityriasis  rubra  pilaris,  [described  by  Devergie  and 
long  known  in  France.] 

In  the  palmar  and  plantar  regions  (Fig.  32)  the  papules  of  lichen 
are  sometimes  horny,  resembling  vesicles  at  first  sight;  this  des- 
quamation gives  rise  to  a  peculiar  cribriform  appearance.  In  other 
cases,  the  eruption  manifests  itself  in  the  form  of  large  irregularly 
outlined  red  and  scaly  spots,  so  that  the  diagnosis  is  far  from  easy. 

Lichen  planus  of  the  buccal  mucosa  is  especially  noteworthy  on 
account  of  its  frequency  and  its  peculiar  appearance.  Familiarity 
with  its  characteristics  may  assist  in  the  diagnosis  of  a  doubtful 
case.  Ignorance  concerning  them  leads  on  the  contrary  to  the 
unfortunately  frequent  confusion  with  leukoplakia  or  syphilis  of 


134  PAPULES  AND  PAPULAR  DERMATOSES 

the  month.  This  localization  of  lichen  is  observed  in  about  one- 
half  [one-third?]  of  the  cases;  it  may  be  primary,  preceding  for  a 
long  time  the  cutaneous  eruption.  Buccal  lichen  planus  is  painless 
and  the  patients  having  it  are  invariably  unaware  of  its  existence. 
The  lesion  consists  either  of  opaline  porcelain-like  spots  or  of  a 
white  network,  closely  resembling,  although  on  a  much  larger  scale, 
the  net  which  has  been  described  in  the  typical  papules  of  the  skin. 

On  the  genital  organs,  notably  on  the  glans  and  prepuce,  umbil- 
icated  papules  and  often  circinate  or  annular  forms  are  observed. 
Vulvar,  urethral  and  anal  lichen  planus  have  also  been  reported. 

The  ordinary  course  of  lichen  planus  is  sluggish.  The  eruption 
appears  insidiously,  progresses  during  a  few  months,  then  persists 
a  variable  time,  sometimes  for  years,  without  changing.  Generally, 
however,  this  course  is  interrupted  by  subacute  attacks,  for  instance 
on  the  occasion  of  physical  or  emotional  disturbances;  the  lesions 
multiply,  new  regions  are  invaded,  there  is  a  recurrence  of  itching. 
Retrogression  is  slow  and  imperceptible,  the  papules  and  patches 
usually  leave  very  persistent  and  suggestive  pigmented  spots. 

The  name  acute  lichen  is  used  for  a  variety  which  takes  a  rapid 
course.  In  these  cases,  an  extensive  eruption  suddenly  appears 
over  large  surfaces  of  the  trunk  or  the  limbs.  It  consists  of  a 
diffuse  redness,  with  swelling  of  the  skin  and  some  desquamation, 
on  which  can  be  made  out  minute  incipient  papules,  the  size  of  a 
needle-point;  sometimes  they  can  be  seen  only  with  a  lens  and 
when  the  skin  is  stretched.  Examination  by  biopsy  shows  that 
even  the  smallest  papules  possess  the  characteristic  structure.  The 
eruption  may  be  accompanied  by  some  systemic  disturbance.  More 
particularly  in  acute  lichen,  although  only  in  exceptional  cases, 
a  few  ephemeral  bulla?  (lichen  ruber  bullosus),  or  sometimes  acu- 
minate lesions  may  be  seen.  Acute  lichen  subsides  in  a  month  or 
two  or  it  may  pass  into  the  chronic  form. 

Pathological  Anatomy. — The  structure  of  the  lichen  planus  papule 
is  characteristic.  The  Malpighian  body,  from  being  at  first  con- 
siderably hypertrophied  (acanthosis)  is  less  markedly  so  later  on, 
when  the  corneal  layer  has  thickened  at  its  expense.  The  granular 
layer  is  preserved  and  even  hypertrophied  (granulosis),  but  the 
keratohyalin  is  unevenly  distributed  in  different  points  of  the  same 
papule.  It  gives  rise  to  the  pathognomonic  network  of  the  white 
or  opaline  streaks.  The  horny  layer  is  thickened,  coherent,  loaded 
with  fat  and  formed  by  normal  non-nucleated  cells  (keratosis);  in 
long-standing  papules,  nucleated  corneal  cells  may  be  found,  and 
corneal  globes  are  sometimes  seen  at  the  orifice  of  a  few  follicles. 

The  papillae  are  not  elongated,  but  broadened  into  cupolas  and 
are  often  slanting.  The  boundary  line  of  the  derma  and  the  epi- 
dermis is  therefore  very  irregular;  it  is  usually  somewhat  obliterated 


LICHEN  PLANUS 


135 


in  places  (Fig.  34,  6r).  Sabouraud  (1910)  has  shown  that  small 
serous  effusions  may  be  encountered  in  the  basal  layer  of  the  epi- 
dermis, as  well  as  a  few  giant  cells  of  epithelial  origin,  either  in 
the  basal  layer  or  much  more  rarely  in  the  subjacent  infiltration. 

The  papillary  body  contains  a  diffuse  infiltration  composed  of 
small  round  cells;  some  of  these  and  sometimes  a  few  Malpighian 
cells,  may  have  undergone  colloid  degeneration.  The  lower  limit 
of  this  infiltration  is  always  markedly  distinct;  beyond  it,  only  a 
few  perivascular  cuffs  are  demonstrable. 

The  papule  is  accordingly  of  the  mixed,  epidermo-dermic  type. 

I  have  described  strictly  analogous  lesions  in  lichen  planus  of 
the  mucous  membranes;  and  in  my  opinion,  the  spots  and  white 
network  are  referable  to  the  abundant  newformation  of  kerato- 
hyaline. 


Fig.  34. — Histology  of  a  lichen  planus  papule.  A,  acanthosis;  B,  granulosis;  C, 
keratosis;  D,  colloid  degeneration;  E,  diffuse  infiltrate;  F,  cupola-shaped  papilla; 
G,  boundary  line  of  derma  and  epidermis.      X  37. 


Diagnosis. — The  common  error  of  mistaking  lichen  for  a  papular 
syphilide  is  not  justified  by  any  real  resemblance. 

Secondary  lichenizations  have  diffuse  outlines;  glistening  facets 
may  be  found,  but  no  papules  as  distinct  as  those  of  lichen  planus; 
and  the  opaline  streaks  are  absent.  Real  difficulties  may  arise, 
however,  in  some  cases. 

Pruriginous  eczema  in  children  is  not  infrequently  associated  with 
small  glistening  papules.  An  observer  who  is  not  aware  of  this 
possibility  may  mistake  the  condition  for  an  eczematized  lichen 
planus  or  a  diffuse  prurigo;  these  papules  are  generally  ephemeral. 

Circumscribed  prurigo  (the  chronic  lichen  simplex  of  Vidal) 
occasionally  very  closely  simulates  lichen  planus.  Its  papules  are 
hemispherical,  instead  of  plane,  less  glistening  and  are  devoid 
of  white  streaks. 

Porokeratosis  of  Mibelli,  which  is  very  rare,  and  the  palmar  and 
plantar  keratoderma  and  porokeratosis  may  cause  serious  difficul- 
ties in  the  differential  diagnosis  from  lichen  planus  of  the  same 
regions. 


(.36  PAPULES  AND  PAPULAR   DERMATOSES 

There  is  a  form  of  lichen  scrofulosorum  with  Mat  and  glistening 
papules,  but  without  an  opaline  network;  it  is  very  rare. 

In  lichenoid  parapsoriasis,  the  analogy  of  the  lesions  with  those 
of  lichen  planus  is  merely  temporary;  the  course  suffices  for  the 
differentiation. 

Acute  lichen  may  be  suggestive  of  erythroderma. 

Etiology  and  Character. — Lichen  planus  is  a  disease  of  adult  life, 
more  common  in  men  than  in  women.  [According  to  the  American 
Dermatological  Association's  statistics,  it  is  seen  once  in  a  little 
more  than  200  cases  of  skin  diseases.] 

It  occurs  so  frequently  in  nervous,  irritable  individuals,  in  con- 
nection with  a  psychic  shock,  violent  emotions,  grief  and  worry, 
accompanied  by  insomnia,  nervous  excitement,  neuralgias,  etc.,  as 
to  suggest  its  interpretation  as  the  cutaneous  manifestation  of  a 
nervous  disturbance.  This  theory  cannot  be  proved.  I  have  not 
found  lichen  planus  to  manifest  itself  with  special  frequency  during 
the  war.  [The  nervous  disturbances  may  well  be  the  effect  rather 
than  the  cause  of  this  dermatosis.] 

Jacquet  and  others  have  advanced  the  view  that  the  eruption 
is  always  secondary  to  scratching.  It  is  perfectly  true  that  a 
patient  suffering  from  lichen  planus  will  sometimes  present  a  linear 
-erics  of  papules  originating  in  a  nail  or  pin  scratch.  Scratching 
an  affected  region  may  therefore  be  held  responsible  for  the  onset 
of  a  more  profuse  eruption.  But  on  the  other  hand,  itching  is 
often  entirely  absent  and  lichen  of  the  mucous  membranes  is  never 
associated  with  any  pruritic  sensation. 

The  nervous  factor  is  sometimes  absent.  Apparently  contagious 
cases  have  been  reported,  as  well  as  other,  more  numerous,  cases  of 
familial  lichen  planus. 

The  pathological  anatomy  would  conform  very  well  with  the 
microbic  theory;  but  this  rests  on  no  really  conclusive  fact.  The 
question  of  etiology  must  therefore  be  left  open. 

Treatment.—  General  Treatment. — General  treatment  ranks  first 
in  order  of  importance,  being  that  of  nervousness  and  pruritus. 
The  dietetic  regimen,  general  hygiene,  and  so  forth,  must  be  regu- 
lated according  to  the  schedule  given  elsewhere.  (See  Therapeutic 
Notes,  Section    12. J 

Hydrotherapy  particularly  the  sedative  lukewarm  douches 
advocated  by  Jacquet  as  by  themselves  alone  sufficient  for  the 
cure  of  obstinate  cases  of  lichen  planus-  is  often  very  efficacious. 
Various  hot  springs  are  of  value. 

Electricity,  in  the  form  of  static  baths  and  especially  high-fre- 
quency currents,  has  yielded  remarkable  results  in  my  experience. 
Radiotherapy  is  applicable  to  localized  eruptions. 

Thibierge    and    Kavaut    have    observed    rapid    cures    following 


LICHEN  PLANUS  137 

spinal  puncture  and  have  recommended  this  procedure  in  the 
treatment  of  the  disease;  its  efficacy  is  not  reliable. 

Among  internal  medicinal  agents,  arsenic  is  regarded  as  a  specific 
by  the  Vienna  School  and  by  a  number  of  dermatologists.  It  is 
prescribed  in  various  forms  and  in  large  doses,  but  at  intervals. 
Sodium  arsenite,  for  example,  may  be  given  in  doses  of  4  mg. 
daily  to  begin  with,  increasing  by  2  mg.  daily  until  12  to  15  mg.  are 
reached,  and  then  diminishing.  Or  from  5  to  12  mg.  of  potassium 
or  sodium  arsenite  may  be  administered  in  daily  injections.  [Several 
American  observers  have  reported  good  results  from  the  internal 
administration  of  mercury.] 

Under  these  conditions  [when  the  treatment  is  prolonged]  arsenical 
poisoning  may  be  expected;  aside  from  digestive  disturbances, 
cramps  and  formication,  there  is  danger  of  palmar  and  plantar 
hyperkeratosis,  or  of  greatly  increased  pigmentation  of  the  spots, 
or  even  the  development  of  melanoderma.  Intravenous  injections 
of  arsenobenzol,  while  not  possessing  the  same  disadvantages, 
cannot  be  unconditionally  recommended. 

Antipyrin,  nerve  tonics,  salicylates,  etc.,  are  unreliable. 

Local  Treatment. — Local  treatment  consists  of  various  topical 
applications,  pastes,  salves  and  plasters  made  with  calomel,  yellow 
oxide,  chrysarobin,  even  with  sublimate;  to  the  mercurials  may  be 
added  phenol,  menthol,  tartaric  or  salicylic  acids.  Collodium  with 
oil  of  cade  is  sometimes  very  successful  in  discrete  eruptions.  Appli- 
cations of  potassium  permanganate,  in  fairly  strong  solution,  have 
been  recommended  by  Hallopeau,  even  against  buccal  lichen 
planus,  the  treatment  of  which  is  extremely  unsatisfactory. 

Atypical  Forms  of  Lichen  Planus. — Of  the  following  dermatoses, 
some  are  varieties  of  Wilson's  lichen,  whereas  others  are  probably 
independent  of  the  same  and  will  ultimately  come  to  be  classified 
in  other  nosographical  groups. 

Atrophic  or  Sclerotic  Lichen  Planus,  studied  by  Hallopeau  and 
myself  in  1887,  is  a  legitimate  lichen  planus,  the  plane  papules 
of  which  become  depressed  in  the  center  which  becomes  cicatricial; 
they  extend  slowly  at  the  periphery  and  become  confluent  with  the 
neighboring  lesions.  The  resulting  atrophic  spots  are  white  or 
nacreous,  rounded  or  poly  cyclical.  On  their  thinned  epidermal 
lining  corneal  granules  are  sometimes  found  lying  in  the  sweat 
and  follicular  orifices.  These  white  spots  may  attain  the  size  of  a 
silver  dollar. 

Histology  shows  that  a  sclerotic  band  has  become  interposed 
between  the  epidermis  and  the  infiltration.  When  the  process  is 
checked,  the  papular  border  and  the  rose-colored  areola  disappear 
but  the  cicatrix  is  indelible  (Fig.  35). 

The  wrists,  forearms,  neck,  breasts,  abdomen  and  sometimes  the 


138 


PAPULES  AXD   PAPULAR   DERMATOSES 


thighs  are  the  regions  in  which  this  variety  of  lichen  has  been 
especially  observed.  Zumbusch  has  described  it  under  the  new 
name  of  lichen  albus,  which  was  not  needed.. 


Fig.  35. — Lichen  planus  atrophicus  on  the  nape  of  the  neck  in  a  woman  aged  fifty- 
three  years. 


1  [G.   36, — Lichen  obtusus  vulgaris  of  the  leg. 


Lichen  Nitidus  of  Pinkus  is  an  eruption  of  small,  flat,  glistening, 
sometimes  slightly  dusky  papules,  which  never  becomes  confluent 
and  causes  no  itching.  It  is  almost  invariably  localized  on  the  penis, 
but  may  be  generalized,  persisting  unchanged  for  years.     Ilisto- 


LICHEN  PLANUS 


139 


logical  sections  show  a  tuberculoid  nodule,  rich  in  giant  cells,  lying 
directly  under  the  epidermis. 

Lichen  Obtusus. — The  name  of  lichen  obtusus  has  been  applied 
to  various  imperfectly  understood  eruptions  with  hemispherical 
papules.  Lichen  planus  obtusus  of  Unna  is  characterized  by  dry 
scattered  elevations,  the  size  of  a  pea,  brownish  or  purplish  in  color, 
not  scaly,  and  only  slightly  pruritic. 


Fig.  37. — Lichen  corneus  hypertrophieus  of  the  leg,  in  a  man  aged  sixty-two  years, 
who  simultaneously  presented  lichen  planus  on  the  back  of  the  hands. 


Lichen  Planus  Moniliformis  of  Kaposi  seems  to  be  a  rare  variety  of 
lichen  planus,  with  large  hemispherical  papules,  arranged  in  strands 
[like  a  string  of  beads]. 

Lichen  Obtusus  Vulgaris  consists  of  large,  faintly  pinkish  or  brown- 
ish papules,  usually  grouped  in  a  single  region  and  even  confluent; 
I  have  observed  it  especially  on  the  anterior  surface  of  the  legs 
(Fig.  36).  It  is  more  or  less  pruritic  and  runs  a  very  protracted 
course.    The  elevations  are  often  covered  with   a  horny  coat. 


1  10  PAPULES  AND  PAPULAR  DERMATOSES 

The  relations  between  this  form  and  lichen  planus  are  doubtful; 
it  is  often  confused  with  the  following: 

Hypertrophic  Lichen  Corneus  or  Lichen  Verrucosus,  consists  of  pink- 
ish or  red  warty  protuberances,  usually  covered  with  very  adherent 
brownish  or  chalky  horny  masses.  They  have  the  dimensions  of 
a  pea  to  those  of  nummular  patches.  They  are  disseminated,  or 
more  frequently  grouped,  or  even  confluent,  in  a  roughly  outlined 
network.  Their  surface  may  have  an  alveolar  appearance,  pro- 
duced by  numerous  corneal  cones  dipping  into  the  cutaneous  pores. 
Itching  is  variable,  intermittent  and  inclined  to  be  nocturnal. 

The  seat  of  predilection  of  the  eruption  is  on  the  legs,  but  it 
may  also  occupy  the  elbows,  the  Hanks  and  buttocks,  etc.  The 
microscope  reveals  a  well-marked  total  epidermic  hypertrophy  and 
a  considerable  elongation  of  the  papilla*. 

I  have  repeatedly  demonstrated  the  coincidence  of  this  lichen 
verrucosus  corneus  with  typical  lichen  planus,  or  with  buccal  lichen 
planus,  I  have  also  seen  lichen  corneus  developing  on  oozing  or 
crusted  eczematous  foci  (Fig.  37). 

It  is,  therefore,  probable  that  various  dermatoses  may  terminate 
in  the  clinical  picture  of  lichen  corneus  hypertrophicus,  eczemas, 
prurigos  and  lichens  appearing  among  these  affections.  The 
course  is  very  slow  and  the  disease  is  extremely  obstinate. 

The  treatment  of  the  atrophic  and  obtuse  lichens  does  not  differ 
from  that  of  lichen  planus. 

Hypertrophic  Horny  Lichen  requires  vigorous  washing  with  soap, 
applications  of  caoutchouc  or  moist  dressings  for  cleansing  purposes, 
followed  by  strong  reducing  agents,  notably  chrysarobin.  It  is 
sometimes  necessary  to  resort  to  the  curette  or  the  thermocautery. 
Hydrotherapy  and  radiotherapy  are  very  valuable  measures  in 
these  cases. 

PAPULES  OF  PRURIGO. 

Prurigo  represents  one  of  the  most  confused  problems  in  derma- 
tology. The  simplest  way  of  settling  it  consists  in  calling  prurigo 
all  primary  itching  which  is  accompanied  by  certain  special  cuta- 
neous reactions,  namely  the  papules  of  prurigo  and  lichenization. 

Pruritus  and  prurigo,  as  disease  conditions,  will  be  described 
further  on  (XXIV). 

Among  their  eruptive  manifestations,  those  which  assume  the 
form  of  papules  arc  the  only  ones  here  to  be  discussed;  it  is  desirable 
to  consider  them  in  connection  with  lichen  papules,  with  which 
they  are  always  liable  to  be  confused. 

There  exist  two  forms  of  papules  in  the  prurigos:  the  papule 
of  strophulus  or  acute  prurigo  and  the  papule  of  genuine  or  chronic 
prurigo. 


PAPULES  OF  PRURIGO  141 

The  Papule  of  Strophulus. — The  papule  of  strophulus  is  an 
elevation  of  the  size  of  a  large  pin-head,  lenticular  shape,  dusky 
or  pinkish  color  and  firm  consistence  (Fig.  148).  Careful  examina- 
tion shows  it  to  be  always  centered  by  a  yellowish  point  which  is 
really  a  minute  vesicle  or  tiny  crust.  It  originates  almost  invari- 
ably in  the  center  of  a  more  or  less  transitory  urticarial  spot.  Dur- 
ing the  first  hours,  it  is  often  necessary  to  stretch  the  skin  at  the 
site  of  this  spot  in  order  to  bring  out  the  papule  hidden  by  it.  The 
papule  will  appear  like  a  droplet  of  wax;  on  palpation  a  firm  round 
induration  is  felt. 

At  the  end  of  four  to  twelve  hours,  the  urticarial  spot  disappears 
and  the  papule  remains  behind.  It  persists  from  eight  to  fifteen 
days;  the  crust  which  crowns  it  is  demonstrable  nearly  to  the  end. 
When  this  crust  has  been  torn  away  by  scratching,  it  becomes 
replaced  by  a  bloody  crust.  In  disappearing,  the  papule  often 
leaves  a  not  very  persistent  pigmented  spot  behind  it. 

In  exceptional  cases,  smaller  papules  are  met  with,  lasting  only 
three  to  four  days;  larger  reddish  papules,  the  size  of  a  lentil; 
papulo-vesicles  with  distinct  vesicles,  sometimes  attaining  the  size 
of  a  pea,  umbilicated  or  not,  with  clear  or  turbid  contents. 

Histological  examination  shows  that  the  strophulus  papule  is 
dermo-epidermic  and  consists  of  papillary  edema  and  vascular 
dilatation  with  a  diffuse  infiltration  of  leukocytes;  edema  of  the 
mucous  body;  a  lenticular  disk  of  colloid  appearance  situated 
directly  under  the  horny  layer  and  composed  of  parakeratotic 
corneal  cells  and  edematous  desiccated  epidermic  cells;  spongiosis 
is  regularly  present  beneath  and  on  the  borders  of  this  disk.  This 
structure  is  characteristic. 

The  papule  of  strophulus,  with  its  associated  urticaria,  is  the 
special  eruptive  lesion  of  acute  prurigo  simplex,  to  which  its  old 
name  of  strophulus  is  advantageously  reapplied.  It  is  also  met  with 
rather  frequently,  but  not  invariably,  in  the  first  stage  of  Hebra's 
prurigo. 

The  Papule  of  Prurigo. — The  papule  of  prurigo  has  the  following 
characteristics :  Its  volume  usually  varies  between  that  of  a  millet 
seed  and  that  of  a  large  pea;  its  form  is  more  or  less  hemispherical, 
rarely  flat;  its  rounded,  sometimes  ovaloid  contours  are  not  quite 
distinctly  outlined;  its  color  is  variable,  sometimes  of  the  same 
shade  as  the  normal  skin  of  the  region,  or  it  may  have  a  more  or 
less  bright  pink,  darkened,  yellowish  or  brownish  hue;  its  consist- 
ence is  more  or  less  firm,  never  soft;  its  surface  is  either  very  smooth, 
almost  glistening,  or  more  often  scaly,  not  infrequently  excoriated 
and  covered  with  a  bloody  crust.  Briefly,  it  presents  a  considerable 
objective  resemblance  to  the  papule  of  lichen  obtusus  (Fig.  36). 

According  to  various  authors,  this  papule  may  sometimes  become 


142  PAPULES  AND  PAPULAR  DERMATOSES 

crowned  with  an  eczematoid  vesicle,  or  it  may  undergo  suppura- 
tion; I  believe  these  are  superadded  lesions  due  to  traumatism  and 
infection. 

The  structure  of  the  prurigo  papule  can  be  defined  in  a  few  words; 
it  consists  of  localized  acanthosis;  edema  and  infiltration  are 
absent  or  slightly  marked;  Jadassohn,  however,  speaks  of  the 
frequent  presence  of  large  numbers  of  eosinophile  cells  in  the 
derma;  Leloir  and  Tavern ier  have  described  an  intra-malpighian 
cavity  containing  clear  fluid  and  few  leukocytes,  said  to  be  char- 
acteristic of  Hebra's  prurigo;  I  have  never  observed  it. 

The  prurigo  papule  is  regularly  met  with  in  Hebra's  prurigo  in 
its  second  stage,  in  the  form  of  a  scattered  eruption;  it  may  reach 
the  size  of  a  hazel-nut  in  prurigo  ferox  (see  Fig.  149).  It  is  some- 
times observed  in  diffuse  prurigo  vulgaris,  but  almost  invariably 
in  circumscribed  prurigo  (chronic  lichen  simplex  of  Yidal).  It 
must  not  be  confused  either  with  the  papule  of  strophulus  or  with 
the  papule  of  lichen  planus  and  especially  not,  as  is  frequently  done, 
with  excoriated  follicular  papules  which  will  be  discussed  in  describ- 
ing the  other  cutaneous  manifestations  of  pruritus  and  prurigo 
(p.  487). 

PAPULAR    SYPHILIDES. 

Papular  eruptions  are  among  the  common  manifestations  of  the 
secondary  stage  of  syphilis  and  their  recognition  is  accordingly 
important. 

They  are  classified,  according  to  the  dimensions  of  the  lesions, 
into  syphilides  with  small  papules,  which  will  be  described  with 
the  folliculoses  (for  they  are  always  peripilar);  syphilides  with 
medium-sized  lenticular  papules  and  syphilides  with  large  papules, 
or  papulo-nummular  syphilides. 

Lenticular  papular  syphilides  are  perfectly  round,  disk-shaped 
protuberances,  of  a  pinkish  (later  red  or  ham-colored)  rarely  cop- 
pery hue,  firm  to  the  touch  and  giving  the  sensation  of  a  sharply 
circumscribed  dermic  infiltration. 

On  their  surface  the  epidermis  is  raised  in  a  fine  glistening  layer; 
when  this  is  detached,  a  scaly  border  is  left,  known  as  Biett's 
collar;  the  last-named  sign  may  be  absent  and  is  moreover  not 
absolutely  pathognomonic.  Not  uncommonly,  there  is  more 
profuse  desquamation  and  the  lesion  may  then  be  named  papulo- 
squamous  syphilide. 

Lenticular  syphilides  are  common,  sometimes  following  the 
roseola  through  a  papular  transformation  of  the  spots  (papular 
roseola),  or  becoming  intermingled  with  the  latter  (erythemato- 
papular  syphilides),  or  they  may  constitute  a  syphilitic  eruption 


PAPULAR  SYPHILIDES  143 

by  themselves.     These  attacks  have  a  tendency  to  recur,  especially 
in  the  course  of  the  first  year,  in  insufficiently  treated  patients. 

The  eruption  is  usually  abundant,  symmetrical,  very  irregularly 
scattered  over  the  trunk  and  limbs,  even  on  the  face  and  on  the 
palmar  and  plantar  surfaces.  It  is  often  associated  with  mucous 
patches,  alopecia,  sometimes  with  pigmented  syphilides,  nodular 
syphilides  or  other  complicated  eruptions. 


Fig.  38. — Eruption  of  lenticular  papular  syphilides,  mixed  with  a  few  follicular 
syphilides. 

It  lasts  from  ten  to  thirty  days  when  treated,  from  two  to  three 
months  in  the  absence  of  specific  treatment.  The  papules  leave 
in  their  place  reddish,  sometimes  pigmented  hyperchromic  spots, 
especially  on  the  lower  limbs,  very  persistent  and  most  distressing 
to  the  patients.  Such  cases  were  described  by  Fournier  under  the 
name  of  syphilides  nigricantes .  The  occurrence  of  atrophic  spots 
or  macules  has  also  been  observed  (Fig.  38). 

Several  deformities  or  irregularities  of  the  lenticular  papules  and 
papulo-squamous  syphilides  are  known  to  occur.     They  become 


144 


PAPULES  AND   PAPULAR   DERMATOSES 


papulo-erosive,  under  the  influence  of  maceration,  in  the  axillary, 
inguinal,  intergluteal  folds,  at  the  umbilicus  and  around  the  geni- 
tals. This  aspect  is  frequently  seen  in  congenitally  syphilitic 
infants,  on  the  buttocks,  the  back,  the  neck,  the  genital  regions  and 
sometimes  involves  the  entire  lower  limits. 

In  the  seborrheal  regions  papular  syphilides  are  arranged  in 
certain  eases  in  manunillate,  circinate  or  irregular-shaped  patches, 
covered  with  greasy  crusts,  these  are  designated  as  seborrheal 
syphilides  and  on  the  forehead  constitute  the  corona  veneris;  they 
are  very  resistant  to  treatment,  unless  appropriate  topical  agents 
are  employed  together  with  the  specific  medication. 

The  psoriatiform,  papulo-crusted  and  fungoid  varieties  of  the 
papular  syphilides  have  been  mentioned  already  or  will  be  discussed 
later. 


Fig.   39.— Arcif 


Aii  interesting  (because  absolutely  pathognomonic)  form  is  that 
of  the  papulo-drcinate  or  arcif orm  [or  annular]  syphilide  (Fig.  39). 
This  is  observed  only  in  the  course  of  the  first  year  and  in  young 
women  who  have  already  been  treated.  [It  is  not  uncommon  in 
the  negro  race  in  both  sexes.]  It  presents  the  appearance  of 
regular  rings,  graceful  arcades  or  complicated  circulations,  on  the 
chin,  around  the  lips  and  nostrils,  or  sometimes  on  the  vulva. 
The  circles  are  continuous  or  formed  by  small  fine-scaly  papules 
having  a  yellowish-pink  color. 

Papulo-nummular  syphilides  are  discoid  or  oval  prominences, 
from  1  to  3  cm.  in  diameter;  on  account  of  their  form  and  their 
ordinarily  oozing  or  crusted  surface,  they  have  been  named  cuta- 
neous patches  (Bazin),  syphilitic  patches  (Legendre),  or  mucous 
patches  of  the  skin. 


LICHEN  SCROFULOSORUM  145 

These  syphilides  are  extremely  common  in  the  ano-genital  region, 
but  may  develop  in  any  skin  fold.  They  are  also  met  with  in 
association  with  a  papulo-lenticular  eruption,  on  the  neck,  the  face, 
the  shoulders,  etc.,  but  are  not  numerous  there.  They  might  be 
confused  with  iodide  eruptions,  but  these  are  pustular  and  grow 
much  more  rapidly. 

All  these  papular  syphilides  have  a  nearly  identical  structure  (Fig. 
31);  they  are  composed  of  an  intradermic  plasma-cell  infiltration 
and  differ  among  themselves  only  by  the  lesions  of  the  epidermis. 

The  diagnosis  of  papular  syphilides  is  usually  easy.  Lichen 
planus,  psoriasis  and  parapsoriasis  differ  from  these  syphilides  by 
the  features  of  their  own  lesions.  The  papules  of  the  diffuse  and 
circumscribed  prurigos  are  distinguished  by  the  very  active  pruri- 
tus by  which  they  are  accompanied.  Hydradenomas  of  the  thorax, 
which  are  very  rare,  have  an  analogous  appearance  but  their 
duration  is  indefinite  and  their  localization  is  strictly  limited. 

Papulo-necrotic  tuberculides  may  give  rise  to  serious  diagnostic 
difficulties,  although  it  is  known  that  they  chiefly  affect  the  limbs, 
that  their  development  is  successive  and  usually  slow,  that  they 
become  hollowed  out  by  ulceration  and  leave  a  cicatrix.  In  a 
given  case,  however,  the  decision  may  have  to  be  based  upon  the 
coexistence  of  other  specific  manifestations,  biopsy  and  serodiagnosis. 
The  diagnosis  of  posterosive  syphiloids  in  the  newborn  is  still 
more  difficult.  Mistakes  are  common  and  seriously  detrimental  to 
infants  wrongfully  suspected  of  syphilis.  The  presence  of  other 
manifestations  of  congenital  syphilis,  the  condition  of  the  parents 
and  the  course  of  the  eruption,  permit  a  positive  diagnosis  in  some 
cases.  The  Wassermann  reaction  of  the  child  and  its  mother  must 
be  determined  in  doubtful  cases  and  sometimes  biopsy  and  a  search 
for  spirochetes  is  called  for. 

LICHEN    SCROFULOSORUM. 

Lichen  scrofulosorum  is  a  papular  eruption  resembling  lichen  in 
its  clinical  appearance,  but  in  its  nature  related  to  the  tuberculides 
or  attenuated  tuberculoses  of  the  skin. 

It  will  be  seen  further  on  that  the  tuberculides  constitute  a  group 
of  dermatoses  of  identical  etiology,  but  extremely  polymorphous 
objective  characters.  The  most  frequent  and  distinct  forms  have 
received  special  names,  the  others  are  considered  as  intermediary 
forms. 

My  description  deals  with  the  most  pronounced  type  of  the 
papular  tuberculides;  but  it  must  be  emphasized  from  the  start 
10 


146 


PAPULES  AND   PAPVLAli   DERMATOSES 


that  there  exist  numerous  atypical  and  less  distinctly  characterized 
varieties. 

Lichen  scrofulosum  of  Hebra,  the  papular  scrofulide  of  Bazin — 
a  better  name  for  vhich  would  be  lichenoid  tuberculide — presents 
the  following  appearance: 

An  eruption  of  small  papules,  of  the  average  size  of  a  pin-head 
slightly  prominent,  flattened,  polygonal,  of  a  pale  yellow  or  more 
rarely  a  dusky  red  color,  of  rather  soft  consistence,  a  surface  smooth 
and  glistening  or  more  commonly  covered  by  a  slightly  adherent 
scaly  layer,  such  is  the  typical  form  (resembling  the  papule  of 
lichen  planus)  which  is,  however,  not  the  most  frequent. 

These  papules  are  almost  invariably  grouped  in  more  or  less 
numerous  nummular  plaques  or  in  patches,  rings,  or  semicircles; 
also  as  an  irregular  network,  the  interpapular  areas  remaining 
normal. 

The  eruptions  usually  occur  on  the  trunk,  especially  the  flanks  and 
loins,  but  may  spread  to  the  limbs  and  exceptionally  to  the  face. 
It  appears  insidiously,  almost  without  pruritus,  persists  during 
several  months  and  then  disappears  leaving  no  trace  of  any  kind. 
Sometimes  recurrences  develop  in  attacks  during  several  years. 


FlG.  40. — Lichen  scrofulosorum,  acuminate  variety.  (This  group  of  papules 
suddenly  appeared  on  the  back  of  a  young  woman  suffering  from  lupus,  shortly  after 
an  injection  of  tuberculin). 


There  are  numerous  varieties,  and  the  following  forms  may  be 
found  associated  with  the  flat  and  glistening  papules,  in  the 
same  or  in  different  regions,  or  constituting  by  themselves  the 
entire  eruption:  conical  or  acuminated  papules,  of  a  rose-red  color 
(Fig.  40)  and  centered  over  a  follicle  the  hair  of  which  may  be 
broken  off  flush  with  the  orifice;  in  other  cases,  conical  papules 
crowned  by  a  vesico-pustule,  of  the  type  of  acne  cachecticorum ; 
or  again,  confluent  lesions  may  form  scaly  polygonal  disks,  of  a 
purplish  or  brownish-red  color,  slightly  infiltrated,  not  very  promi- 
nent, which  resemble  psoriasis  or  some  of  the  eczematides;  and 
finally,  the  eruption  may  present  a  mixture  of  follicular  papules  and 


LICHEN  SCROFULOSORUM  147 

patches  dotted  with  acuminate  lesions  suggestive  of  pityriasis  rubra 
pilaris  or  lichen  spinulosis. 

Under  the  heading  of  lichen  scrofulosorum  there  should  also  be 
grouped,  according  to  Boeck,  as  deformed  or  attenuated  varieties: 
his  disseminated  papulosquamous  tuberculide;  his  eczema  scrofulo- 
soram,  characterized  by  crusted  and  oozing  patches  with  an  infiltrated 
base  constantly  recurring  at  the  same  points;  certain  forms  of 
pityriasis  simplex  of  the  face  in  children,  arranged  in  circumscribed, 
red,  fine-scaling  patches  and  accompanied  by  large  cervical  glan- 
dular swellings. 

Lichen  scrofulosorum  is  observed  at  all  ages,  but  occurs  by  predi- 
lection in  children  and  youthful  individuals  suffering  from  glandular 
or  bony  tuberculosis  or  from  sluggish  visceral  tubercular  lesions.  It 
has  been  known  to  follow  acute  diseases,  such  as  measles,  etc. 

The  papules  are  formed,  as  was  first  shown  by  Jacobi  and  Sack, 
by  a  dermic  infiltration  having  almost  invariably  the  constitution 
of  characteristic  tubercular  follicles,  with  giant  cells,  but  with  a 
slight  tendency  to  caseous  degeneration ;  these  tubercles  are  situated 
in  the  papillary  body  or  around  a  pilo-sebaceous  follicle. 

Jacobi,  Sack  and  Wolff  succeeded  in  finding  the  Koch  bacillus  in 
their  specimens  and  in  a  few  of  their  cases  guinea-pig  inoculation 
proved  positive. 

A  general  and  local  tuberculin  reaction  is  practically  constant; 
Jadassohn  obtained  a  positive  reaction  in  14  out  of  16  cases. 
Schoeninger,  Buzzi  and  myself  have  observed  the  appearance  of 
lichen  scrofulosorum  immediately  after  injections  of  tuberculin, 
which  undoubtedly  merely  served  to  bring  out  latent  lesions  (Jadas- 
sohn, 1896). 

The  diagnosis  of  lichen  scrofulosorum  may  present  very  con- 
siderable difficulties.  In  view  of  its  habitual  polymorphism,  it  is 
advisable  to  examine  not  only  one  eruptive  group  but  the  erup- 
tion as  a  whole ;  thereby  guarding  against  confusion  with  the 
eczematides,  lichen  planus,  acne  cornea,  abortive  forms  of  pityriasis 
rubra  pilaris,  etc. 

The  differential  diagnosis  from  the  follicular  lichenoid  syphilides 
is  sometimes  almost  impossible,  even  on  examination  by  biopsy. 
The  Wassermann  reaction  is  of  great  help  in  these  cases. 

The  treatment  is  that  of  tuberculosis  in  general:  fresh  air,  sun- 
light, cod-liver  oil,  calcium  compounds  and  arsenic;  tuberculin  in 
very  minute  doses  or  novarsenobenzol  may  lead  to  rapid  improve- 
ment. Locally  weak  reducing  agents  and  cod-liver  oil  ointments 
have  been  recommended. 


CHAPTER  VIII. 
VESICLES  AND  VESICULAR  DERMATOSES. 

Vesicles  are  small  circumscribed  elevations  of  the  epidermis 
containing  a  clear  fluid.  Their  size  varies  from  that  of  a  pin-head  to 
that  of  a  pea;  their  form  is  hemispherical,  or  sometimes  acuminate 
or  umbilicated;  their  outline  is  round;  or,  as  the  result  of  confluence 
they  may  assume  an  angular  or  polycyclical  configuration. 

The  contents  of  the  vesicles  are  fluid  and  transparent  like  water 
or  yellowish  and  serous.  It  is  sometimes  necessary  to  prick  the 
roof  with  a  needle  in  order  to  demonstrate  the  presence  of  the  fluid 
and  its  properties.  The  contents  are  apt  to  become  cloudy  or  turbid 
after  a  time;  sometimes  they  are  hemorrhagic  from  the  start. 

As  the  result  of  desiccation,  the  vesicles  are  transformed  into 
crusts  whose  origin  is  indicated  by  their  shape  and  arrangement. 

On  the  mucosa?  and  semimucosse,  as  well  as  in  regions  where  skin 
rests  against  skin,  the  vesicles  rupture  very  readily  leaving  red 
erosions  or  often  diphtheroid  lesions  of  rounded  or  polycyclic 
contours. 

Modes  of  Formation  of  Vesicles. — They  always  result  from  an 
accumulation  of  plasma  in  the  epidermis.  Vesiculation  may  occur 
in  three  different  ways  which  are,  however,  frequently  combined. 

In  the  first,  or  parenchymatous  vesiculation,  the  fluid  accumulates 
first  in  the  interior  of  the  Malpighian  cells  and  the  resulting  uni- 
cellular vesicles  become  confluent  with  each  other.  This  so-called 
"alteration  cavitaire"  of  Leloir  predominates  in  smallpox,  vaccinia, 
etc. 

In  a  second  type,  or  interstitial  vesiculation,  the  edema  is  inter- 
cellular, compressing  and  stretching  the  Malpighian  cells  which 
are  drawn  out  into  a  net,  the  threads  of  which  finally  rupture,  pro- 
ducing the  spongioid  state  of  Unna,  the  spongiosis  of  Besnier.  The 
vesicles  of  eczema  are  produced  in  this  way  (Fig.  5). 

In  a  third  type,  the  edema  is  likewise  intercellular,  but  the  cells 
become  globular,  are  detached  from  each  other  and  float  in  the 
fluid,  undergoiag  a  cloudy  or  fibrinous  degeneration,  sometimes 
becoming  hypertrophied  with  multiplication  of  their  nuclei.  This 
is  the  ballooning  alteration  of  Unna,  which  predominates  in  the  vesi- 
cles of  varicella,  zona  (Fig.  41),  herpes,  etc. 

Whatever  the  mechanism  of  their  production,  vesicles  always 


MODES  OF  FORMATION  OF  VESICLES 


149 


result  from  an  inflammatory  process  and  constitute  acute  eruptions 
on  a  hyperemic  base. 

Vesicles  differ  from  bullce  not  only  by  their  usually  smaller 
volume  but  also  by  their  mode  of  formation.  In  contradistinction 
to  bullae,  they  are  frequently  multilocular,  at  least  at  their  inception. 

They  differ  from  serous  cysts,  notable  from  the  hydrocystomas 
and  lymphatic  varices  which  may  simulate  them,  by  the  intra- 
epidermic  seat  of  their  fluid ;  they  can  be  opened  by  puncture  without 
causing  hemorrhage. 


Fig.  41. — Section  of  a  zona-vesicle  on  the  tenth  day.  Vesiculation  through  bal- 
looning alteration ;  in  the  center  of  the  vesicle  all  the  cells  of  the  rete  are  degenerated 
and  the  papillae  are  exposed.  In  the  cutis  an  abundant  infiltration  of  lymphoid 
cells  is  seen.     X  50. 


Vesicular  Dermatoses. — Vesiculation  is  observed  in  the  eruptive 
fevers,  variola,  varicella  and  vaccinia,  for  which  the  reader  is 
referred  to  text-books  of  general  medicine. 

In  eczema  from  any  cause,  vesiculation  is  very  common;  it  has 
even  been  considered  as  characteristic  of  the  eczematous  process. 
It  may  be  absent,  however,  and  at  any  rate  represents  merely 
a  stage  or  episode  of  eczema,  which  was  discussed  in  a  chapter  bv 
itself  (IV). 

The  vesicles  of  cutaneous  trichophytosis,  formerly  called  herpes 
circinatus  seem  to  me  to  be  of  eczematous  character;  they  will  be 
mentioned  in  the  chapter  on  parasitic  dermatoses,  as  will  also  those 
which  complicate  scabies. 

Sudamina,  notwithstanding  their  small  size,  are  not  vesicles  but 
minute  subcorneal  bullae;  they  will  be  discussed  together  with  the 
hidroses. 

In  recurrent  polymorphous  pemphigus,  commonly  known  as 
dermatitis  herpetiformis  of  Duhring,  genuine  vesicles  are  found  at 
the  same  time  as  real  bulla?;  this  affection  is  in  every  respect  related 
to  the  bullous  dermatoses. 

The  eruption  of  strophulus  is  usually  papular;  it  is  exceptional  for 
the  microscopical  vesicle  which  crowns  its  papules  to  assume  a 


L50  VESICLES  AND   VESICULAR  DERMATOSES 

development  rendering  it  visible  to  the  naked  eye;  however,  certain 
very  rare  eases  have  simulated  varicella.  This  affection  belongs  to 
the  group  of  the  prurigos. 

In  this  chapter  there  remains  to  be  studied  only  herpes,  zona 
and  the  zosteriform  eruptions.  These  are  purely  and  exclusively 
vesicular  eruptive  syndromes. 

HERPES. 

Herpes  is  an  acute  eruption  of  a  cluster  of  vesicles,  varying  in 
number  and  originating  on  an  erythematous  base,  situated  any- 
where, although  having  a  predilection  for  the  face,  around  the  mouth 
and  the  nose  and  for  the  genital  region.  The  affection  is  extremely 
common  and  known  to  the  laity  under  the  name  of  "fever  blister." 

The  word  herpes  formerly  had  a  much  more  restricted  significance. 
The  terms  herpetism,  herpetides,  no  longer  possess  any  accurate 
meaning.  The  name  of  herpes  is  still  used  for  some  dermatoses  of 
very  variable  kinds,  such  as  herpes  circinatus,  herpes  gestationis, 
herpes  iris,  herpes  cretaceus,  etc.,  which  are  in  no  way  related  to 
genuine  herpes.    Zona  is  also  known  as  herpes  zoster. 

Symptoms. — Frequently  preceded  a  few  hours  by  shooting  pains 
or  a  tense  and  burning  sensation,  herpes  appears  in  the  form  of  a 
congestive  edematous  spot,  which  promptly  becomes  covered  with 
uniform  vesicles,  the  size  of  a  pin-head,  with  clear  contents,  from  two 
or  three  to  several  dozen  in  number.  These  vesicles  lie  very  close 
together  and  sometimes  become  confluent.  They  are  rarely  hemor- 
rhagic. There  may  be  several  as  if  accidentally  scattered  groups. 
The  lymph  glands  are  slightly  enlarged. 

The  herpetic  vesicles  became  turbid,  then  opaque  and  shrivel  up, 
forming  yellow  or  brown  crusts  which  become  detached  at  the  end 
of  eight  to  ten  days,  leaving  a  temporarily  red  spot,  but  never  a 
permanent  scar.     Herpes  has  a  marked  tendency  to  recurrence. 

The  seat  of  election  of  herpes  is  the  lips,  the  nostrils,  or  any  part 
of  the  face;  or  the  genital  regions.  Herpes  is  also  not  infrequently 
seen  on  the  lobes  of  the  ears,  the  nipples  and  the  mucous  membranes; 
but.  is  much  rarer  on  the  trunk  and  limbs.  As  a  rule,  only  one  of 
these  regions  is  affected  at  the  same  time.  In  the  course  of  the  War, 
however,  I  was  enabled  to  observe  in  young  soldiers  recently  vac- 
cinated against  typhoid  fever,  profuse  eruptions  of  herpes  occupying 
simultaneously  the  forehead,  the  nose,  both  lips,  the  mouth,  the 
chin,  the  ears,  the  neck,  and  in  one  instance  one  of  the  upper  extremi- 
ties; the  condition  being  suggestive  of  so-called  multiple  zona. 

Herpes  genitalis  [or  progenitalis]  is  especially  noteworthy  on 
account  of  the  liability  to  misinterpretation.  Li  men,  it  occupies 
the  balano-preputial  sulcus,  the  glans,  the  prepuce,  or  more  rarely 


HERPBS 


151 


the  meatus.  On  the  parts  covered  by  the  clothing,  it  is  rapidly 
transformed  into  erosions.  These  are  very  superficial,  isolated  or 
confluent,  round  or  polycyclic  and  microcyclic,  red  or  diphtheroid; 
some  fluid  can  be  squeezed  out  of  them  and  they  are  slightly  painful. 
Herpes  is  not  indurated  at  the  base,  provided  it  is  not  improperly 
treated  or  abused,  and  heals  in  at  most  eight  or  ten  days.  [On  the 
glans  a  certain  degree  of  induration  is  common  and  must  be  con- 
sidered in  making  a  diagnosis.]  When  the  lesion  has  been  cauterized 
or  treated  with  irritants  or  antiseptics  (silver  nitrate,  sublimate, 
tincture  of  iodin,  aristol,  etc.),  always  an  improper  procedure,  it 
may  become  indurated,  associated  with  inflammatory  phimosis  and 
painful  swollen  glands,  ulcerate  and  last  several  weeks.  In  such  cases 
an  immediate  diagnosis  is  extremely  difficult,  sometimes  impossible 
before  the  inflammation  has  been  relieved  by  soothing  applications. 


Fig.  42. — Profuse  vulvar  herpes,  showing  eruption  of  relatively  moderate  severity. 


In  women,  herpes  may  occupy  any  portion  of  the  vulva,  presenting 
the  same  features  as  in  the  male.  It  is  met  with  exceptionally  in  the 
vagina  and  the  cervix  uteri. 

A  profuse  vulvar  herpes  sometimes  occurs  (Fig.  42)  with  some 
fever,  severe  burning  sensation,  very  marked  local  edema,  extensive 
patches  covered  with  agglomerated  or  confluent  vesicles,  extending 
from  the  vulva  to  the  pubis,  the  internal  surface  of  the  thighs  and 
in  the  intergluteal  fold.  The  macerated  vesicles  rapidly  break,  are 
transformed  into  erosions  or  become  covered  with  a  diphtheroid 
layer  and  secrete  an  offensive  muco-purulent  discharge.    The  glands 


L52 


VESICLES  AND    VESICULAR   DERMATOSES 


are  swollen  and  painful.  The  patient  suffers  great  inconvenience  and 
is  confined  to  bed.  Healing  takes  place  in  fifteen  or  twenty  days. 
In  some  cases  under  my  observation,  the  lesions  became  promi- 
nent after  epidermization  had  occurred,  closely  simulating  papular 
mucous  patches. 

Aside  from  the  inconvenience  and  actual  pain  caused  by  it,  genital 
herpes  is  important  on  account  of  its  tendency  to  recurrence  and 
because  it  prepares  the  soil  for  severe  infections,  soft  chancres  and 
syphilis,  in  persons  exposing  themselves  to  risk  of  these  diseases. 


I  K..    13.      Recurrent  herpes  of  the  che 
taken  two  years  previously  by  Brocq,  is  s 
280;  illustrating  a  more  discrete  eruption  i 


\  photograph  of  the  same  young  girl, 
n  in  his  Traite  de  Dermatologie,  ii,  p. 

ie  same  a  iva  . 


It  must  also  be  kept  in  mind 
or  accompany  the  onset  of 


t  an  eruption  of  herpes  may  precede 
/philitic  chancre  which  may  conse- 
ain  unrecognized  for  some  length  of 


quently  pass  unobserved  ot 
time. 

Herpes  buecalis  is  less  common,  and  is  usually  met  with  in  connec- 
tion with  a  profuse  herpes  of  the  lips  or  the  face;  it  may  occupy 
the  mucosa  of  the  cheeks,  the  palate  and  the  tongue.  It  is  often 
bilateral.     Its  vesicles  are  ephemeral. 

Herpes  of  the  pharynx  seems  to  constitute  one  of  the  varieties  of 
herpetic  angina,  characterized  by  the  abruptness  of  its  onset,  the 


HERPES  153 

rapidly  rising  temperature,  the  severity  of  the  local  pain  and  the 
marked  general  phenomena.  Vesicles  are  occasionally  found,  but 
more  often  polycyclic  erosions,  diphtheroid  or  not,  which  succeed 
them.  In  doubtful  cases,  these  erosions  can  be  brought  out,  as  on  all 
mucous  membranes,  by  painting  them  with  a  weak  solution  of  silver 
nitrate,  or  better  with  a  watery  solution  of  chromic  acid,  1  to  50  (L. 
Jullien).    The  glands  are  usually  swollen  and  painful. 

Heroes  conjunctivalis  represents  one  of  the  forms  of  phlyctenular 
conjunctivitis. 

Recurrent  herpes  is  that  form  which  recurs,  not  accidentally  and 
at  any  point,  but  with  a  certain  periodicity  and  in  a  practically 
constant  region. 

Certain  women  have  an  eruption,  either  around  the  mouth  or  on 
the  genitals,  at  nearly  every  menstrual  period  (catamenial 
herpes) . 

Recurrent  pro  genital  herpes,  more  particularly  observed  in  men, 
is  considered  by  Diday  and  Doyon  as  related  to  an  existing  or 
preceding  venereal  disease,  especially  soft  chancre,  gonorrhea  and 
syphilis. 

Recurrent  herpes  of  the  face  affects  children  and  youthful  indi- 
viduals, returning  periodically  several  times  in  the  course  of  the 
year  on  the  same  cheek,  for  ten  years  or  more  (Fig.  43). 

Recurrent  herpes  of  the  buttock  occurs  in  adults  of  both  sexes,  and 
takes  a  more  variable  course. 

Recurrent  herpes  of  the  mouth,  pointed  out  by  A.  Fournier,  the 
distress  of  some  old  syphilitics,  is  referred  either  to  remains  of  long- 
cured  specific  lesions,  or  to  abuse  of  mercury. 

These  various  recurrent  herpetes  are  not  infrequently  associated 
with  neuralgic  pains,  burning  sensations,  painful  tension,  glosso- 
dynia,  etc. 

Etiology. — Herpes  is  observed  at  any  age,  but  especially  during 
youth  and  maturity.  Its  causes  are  complex.  There  undoubtedly 
exists  a  traumatic  herpes;  dentists,  for  example,  are  familiar  with 
the  herpes  developing  around  the  mouth  as  a  sequel  of  dental  opera- 
tions ;  on  the  other  hand,  herpes  of  the  vulva  is  not  uncommon  after 
the  first  sexual  intercourse.  In  both  cases,  the  patients  are  much 
inclined  to  suspect  that  they  have  been  infected. 

Many  cases  of  recurrent  herpes  of  the  nose,  the  lips,  etc.,  have 
seemed  to  me  to  be  related  to  a  chronic  irritation  of  the  neighboring 
cavities,  dental  caries,  alveolitis,  pulpitis,  gingivitis,  rhinopharyngitis, 
sinus  inflammations,  otitis,  etc.  The  nervous  and  probably  reflex 
character  of  many  cases  of  herpes  is  therefore  obvious.  On  the  other 
hand,  there  are  cases  of  symptomatic  herpes,  in  certain  infections. 
Herpes  is  known  to  be  common  in  pneumonia,  epidemic  cerebro- 
spinal meningitis,  influenza,  etc.    Sometimes  a  high  fever  of  a  few 


154  VESICLES  AND    VESICULAR   DERMATOSES 

days'  duration  is  terminated  by  an  eruption  of  herpes,  whence  the 
assumption  of  a  herpetic  fever. 

A  fairly  well  marked  lymphocyte  reaction  of  the  cerebrospinal 
fluid  was  noted  by  Ravaut  and  Darre  in  21  of  2(5  cases  of  genital 
herpes. 

The  disease  is  not  contagious,  nor  can  it  be  inoculated.  Neverthe- 
less, it  is  difficult  to  reject  the  idea  that  such  an  acute  and  severe 
dermo-epidermic  lesion  often  accompanied  by  glandular  enlarge- 
ment, constitutes  an  [infectious]  inflammatory  reaction  rather  than  a 
"  trophic  disturbance." 

Treatment. — Herpes  of  the  skin  requires  no  active  treatment, 
it  suffices  to  cover  it  with  a  bland  powder;  herpetic  eruptions  can 
sometimes  be  aborted  by  dressings  with  absolute  alcohol  (90  per 
cent),  or  with  borated  or  camphorated  alcohol;  but  failures  are  the 
rule.  Watery  dressings  and  ointments  are  injurious,  except  in  the 
stage  of  complete  desiccation. 

Genital  herpes  must  be  gently  treated;  all  irritant  applications 
involve  the  risk  of  changing  its  appearance  and  prolonging  its  dura- 
tion. It  suffices  to  wash  or  bathe  it  with  lukewarm  boiled  or  borax 
water,  or  an  infusion  of  bran;  to  powder  it  with  talcum,  or  zinc 
oxide,  or  bismuth  subgallate.  Touching  with  a  drop  of  silver  nitrate, 
5  per  cent. ,  is  permitted  and  useful ,  but  only  when  the  diagnosis  is  posi- 
tive and  when  the  erosion  fails  to  become  covered  with  epidermis  at 
the  end  of  a  few  days.  [Inasmuch  as  a  herpes  may  lodge  a  spirochetal 
infection  cauterization  must  in  general  be  avoided.]  Profuse  herpes 
of  the  vulva  requires  rest  in  bed ;  the  pain  is  relieved  by  poultices  of 
starch  or  cooling  creams. 

In  the  case  of  recurrent  herpes,  the  essential  point  is  the  dis- 
covery of  the  initial  focus  of  chronic  irritation  and  its  removal. 
Radiotherapy  has  repeatedly  proved  successful  in  my  experience 
in  the  cure  of  recurrent  herpes  of  the  buttock  and  the  cheek. 

ZONA. 

Zona— or  herpes  zoster — is  an  acute  eruption  of  vesicles,  grouped 
upon  erythematous  patches  and  ordinarily  located  along  the  dis- 
tribution of  a  nerve,  on  only  one  side  of  the  body.  Its  development 
is  approximately  cyclic;  it  recurs  but  rarely. 

Symptoms. — The  eruption  appears  suddenly  and  is  accidentally 
discovered  by  the  patient,  or  it  may  be  preceded  by  prodromata 
and  accompanied  by  pains. 

At  the  onset,  nothing  is  seen  but  slightly  elevated  erythematous 
patches,  with  a  shagreened  surface,  of  oval  or  irregular  outlines, 
from  a  single  one  to  twenty  in  number,  generally  half  a  dozen, 
separated  by  areas  of  healthy  skin.    At  the  end  of  a  few  hours, 


ZONA  155 

at  most  a  day,  vesicles  form  first  in  the  center,  then  on  the  entire 
patch,  and  rapidly  increase  in  size;  they  become  tense,  pearly, 
uniform,  from  the  size  of  a  small  to  a  large  pin-head.  They  lie  close 
together,  more  rarely  discrete,  sometimes  confluent. 

Their  fluid  content  becomes  opalescent  and  turbid,  even  purulent, 
by  the  third  day,  while  at  the  same  time  the  plaque  fades  and 
flattens;  desiccation  begins  from  the  fourth  to  fifth  day  and  is  com- 
pleted by  the  eighth  to  twelfth  day ;  the  crusts  do  not  fall  off  until 
the  end  of  twelve  to  twenty  davs. 


Fig.  44. — Zona,  on  the  tenth  day  of  the  eruption,  occupying  especially  the  cuta- 
neous territory  of  the  II  and  III  left  lumbar  roots.  Near  the  groin  the  patches  are 
confluent,  the  largest  vesicles  are  hemorrhagic;  numerous  incomplete  vesicles  are  also 
seen.    Near  the  knee  the  patches  are  isolated  and  typical. 

The  onset  of  the  various  patches  is  usually  not  simultaneous  but 
successive,  in  the  course  of  two  or  three  days,  so  that  several  stages 
can  be  observed  at  the  same  time  (Fig.  44).  It  frequently  happens 
that  the  eruption  remains  incomplete  on  certain  patches,  especially 
the  last  to  appear.  From  the  start,  or  at  the  end  of  one  or  two 
days,  the  fluid  of  the  vesicles  may  assume  a  sanguinolent  character, 
constituting  hemorrhagic  zona. 

It  is  rare  for  the  vesicles  to  rupture.  When  they  are  opened  in 
the  stage  of  suppuration,  erosions  or  even  fairly  deep  ulcerations 
which  heal  slowly  are  found  beneath  them ;  in  this  case,  the  eruption 
leaves  behind  it,  not  only  brownish  macules,  as  is  usual,  but  indelible 
white  scars  with  pigmented  halos,  sometimes  cheloids,  having  a 
characteristic  distribution.  This  possibility  must  be  mentioned  to 
the  patient. 

In  cachectic  or  weak  and  senile  individuals,  genuine  sloughing 


156  VESICLES   AND    VESICULAR   DERMATOSES 

scars  may  supervene,  representing  gangrenous  zona,  with  a  prognosis 
sometimes  serious. 

The  lymph  glands  corresponding  to  the  territory  of  a  zona  are 
nearly  always  enlarged,  sometimes  before  the  eruption  appears. 
Outside  of  this  territory,  the  skiu  is  healthy.  However,  the  possible 
presence  of  aberrant  vesicles,  at  a  distance  from  the  regional  eruption, 
has  been  pointed  out  by  Tenneson.  In  a  contribution  to  this  sub- 
ject (dedicated  by  me  to  Professor  Barduzzi,  of  Livorno,  in  1911) 
it  was  noted  that  this  observation  is  correct,  but  that,  leaving  out 
of  consideration  the  ordinary  follicular  inflammations  and  lesions 
of  miliary  impetigo  which  may  accompany  the  disease,  genuine 
aberrant  vesicles  in  zona  are  relatively  rare.  [During  an  outbreak 
of  smallpox  in  New  York  in  1900  I  observed  several  cases  of  gener- 
alized herpes  zoster  in  which  the  eruption  was  so  extensive  as  to 
require  careful  examination  before  varicella  could  be  excluded.] 

Pain  is  variable  or  may  be  absent.  Almost  invariably,  however, 
zona  is  either  preceded  for  several  days  or  even  several  weeks,  or 
accompanied,  which  is  more  common — or  followed,  by  neuralgic 
pains;  these  pains  are  continuous  or  paroxysmal  and  may  assume 
all  possible  forms,  especially  a  severe  burning  sensation  (hence  the 
popular  name  of  St.  Anthony's  fire).  The  patches  themselves  are 
sometimes  anesthetic,  it  is  claimed,  but  really  almost  invariably 
hyperesthetic.  The  frequency,  severity  and  duration  of  the  pains 
arc  dependent  upon  the  age  of  the  patient;  they  are  usually  absent 
in  children,  but  in  aged  individuals  may  persist  indefinitely,  causing 
extreme  distress. 

The  eruption  of  zona  may  be  preceded  by  general  phenomena, 
malaise,  prostration,  anorexia,  with  a  transitory  fever  of  39°  or  -40° 
[102°-104°].  In  this  case,  the  infectious  behavior  of  the  disease, 
its  sometimes  epidemic  and  immunizing  character,  have  caused  it 
to  be  likened  to  the  eruptive  fevers:  the  zoster  fever  of  Landouzy  and 
Erb.   The  course  of  the  disease  may  be  described  as  nearly  cyclical. 

Among  the  localizations  of  zona,  the  most  common  is  intercostal 
zona,  to  which  the  disease  owes  its  name.  It  covers  the  thorax  or 
the  abdomen  like  a  half-belt,  without  passing  more  than  a  few 
millimeters  at  most  beyond  the  median  line.  When  it  occupies  the 
territory  of  the  first  intercostal  nerves,  it  follows  the  anastomotic 
branch  which  the  second  intercostal  nerve  sends  to  the  internal 
brachial  cutaneous  nerve  down  the  inner  surface  of  the  arm. 

Cervical  zona,  which  affects  all  or  only  some  of  the  branches  of 
superficial  cervical  plexus,  is  likewise  fairly  common  and  the  same 
remark  applies  to  lumbo-abdominal  and  genito-crural  zona.  Periph- 
eral zonas,  affecting  the  limbs,  are  more  unusual. 

Ophthalmic  zona,  corresponding  to  the  superior  branch  of  the 
trigeminal  nerve,  is  frequent  and  grave  on  account  of  its  possible 


ZONA  157 

sequelae.  It  presents  frontal,  palpebral,  nasal,  even  pituitary 
patches  and  in  two-thirds  of  the  cases  gives  rise  to  ocular  lesions, 
especially  of  the  conjunctiva  and  cornea,  lesions  of  the  iris  and 
amblyopia  being  less  common.  Anesthesia  of  the  cornea,  corneal 
perforation,  irido-choroiditis  and  retinitis  have  been  reported  but 
are  very  rare.  Ophthalmic  zona  must  not  be  confused  at  the  start 
with  erysipelas  or  with  keratoconjunctivitis  from  other  causes. 

Zonas  of  the  mucous  membranes,  buccal,  pharyngeal,  etc.,  are  of 
very  exceptional  occurrence. 

Zona  is  almost  invariably  unilateral  and  may  occupy  the  territory 
of  a  single  nerve ;  as.  a  rule,  however,  it  spreads  over  the  territory  of 
two  or  even  three  neighboring  spinal  roots, 

Exceptionally,  cases  of  double  or  bilateral,  alternating,  multiple,  or 
even  generalized  zona  are  encountered,  such  as  a  case  reported  by 
Colombini  in  1893. 

Zona  usually  occurs  only  once  in  a  life-time,  but  recurrences  have 
been  noted  in  a  few  instances.  So-called  zonas  with  multiple  recur- 
rences belong  to  the  zosteriform  eruptions. 

Etiology  and  Pathogenesis. — Zona  affects  all  ages  and  both  sexes 
equally.  It  is  slightly  more  common  in  the  spring.  The  cause  as 
a  rule  remains  entirely  obscure.  It  has  been  observed  to  follow  after 
severe  traumatisms,  violent  emotions;  to  occur  in  the  course  of 
infections  or  general  diseases,  at  the  beginning  or  in  the  course  of 
tuberculosis  (Leudet),  pneumonia,  pleurisy,  syphilis,  cerebrospinal 
meningitis,  mumps,  carbon  monoxid  poisoning,  arsenic  medication 
(Hutchinson,  Neilson),  diabetes,  cancer,  etc. 

A  number  of  circumstances  indicate  the  infectious  nature  of  zona, 
at  any  rate  in  many  cases.  It  is  true  that  the  disease  is  not  con- 
tagious, but  it  sometimes  seems  to  be  vaguely  epidemic,  in  the  sense 
that  several  persons  from  the  same  environment  are  attacked  at 
intervals  of  a  few  days.  It  may  be  accompanied  by  general  phe- 
nomena; glandular  swelling  is  usually  present.  Sabrazes  and  Mathis 
have  demonstrated  the  occurrence  of  hyperleukocytosis  in  the  course 
of  zona,  especially  of  the  polynuclears  and  the  eosinophiles.  Finally, 
an  attack  of  zona  usually  confers  immunity  against  another.  The 
pathogenic  agent,  however,  has  not  as  yet  been  demo  istrated. 

On  the  other  hand,  the  relations  of  zona  with  the  nervous  system 
are  very  striking,  in  the  distribution  of  the  eruption  as  well  as  the 
associated  neuralgias.  I  have  seen  a  case  of  ophthalmic  zona 
following  upon  a  severe  contusion  of  the  skull  in  an  automobile 
accident.  Mme.  Dioudonnat-Lempert  devoted  her  thesis  (1914) 
to  the  study  of  cephalic  or  cervical  zona  of  dental  origin.  Lesion 
of  a  nerve  branch  in  the  course  of  a  mercurial  injection  may  give 
rise  to  a  cluster  of  zona-vesicles  along  its  area  of  distribution. 
Otic  or  para-auricular  zona  is  not  infrequently  associated  with 
facial  paralysis. 


i:»S  VESICLES  AND   VESICULAR  DERMATOSES 

It  lias  recently  been  shown  that  in  the  course  of  syphilis,  zona 
may  indicate  a  premature  syphilitic  meningitis  which  affects  the 
posterior  roots,  or  it  may  precede  tabes  and  general  paralysis.  Zona 
is  also  sometimes  encountered  in  syringomyelia,  in  dementia, 
vertebral  tuberculosis,  cancer  of  the  vertebra,  etc.  It  is  often  accom- 
panied by  lymphocytosis  of  the  cerebrospinal  fluid ;  in  different  cases, 
this  may  exist  prior  to  the  eruption,  coincide  with  it,  or  follow  several 
days  later;  or  it  may  be  entirely  absent.  More  rarely,  rigidity  at 
the  nape  of  the  neck,  Kernig's  sign,  retardation  of  the  pulse,  head- 
ache, etc.,  have  been  noted. 

Numerous  authors  have  demonstrated  neuritis  or  degeneration 
of  the  nerves  in  the  affected  area.  However,  as  the  distribution  of 
zona  is  far  from  being  always  in  exact  conformity  with  the  distribu- 
tion of  the  corresponding  peripheral  nerves,  a  lesion  of  the  spinal 
root  and  especially  of  the  spinal  ganglia  is  now  held  to  be  responsible. 
Following  Baerensprung  and  Charcot,  various  observers  have 
formed  hemorrhagic,  inflammatory,  or  degenerative  lesions  of  the 
spinal  ganglia  and  the  posterior  roots  in  cases  of  zona;  among  these 
writers,  Head  and  Campbell  must  be  specially  mentioned  (in  31 
cases).  Head  in  England,  Brissaud,  Achard,  and  others  in  France, 
have  endeavored  to  refer  zona  to  a  lesion  of  a  spinal  or  metameric 
segment. 

At  the  present  writing,  the  conclusion  seems  justified  that  the 
metameric  theory  is  probably  true  for  certain  cases;  that  the  radicular 
and  ganglionic  theory  serves  to  explain  the  great  majority  of  zonas, 
as  has  been  confirmed  by  anatomical  findings;  finally,  that  the 
peripheral  nervous  theory  applies  to  certain  rare  cases. 

Granted  that  the  necessary  pathogenic  condition  of  zona  is  a 
lesion  at  some  point  in  the  course  of  neurons  which  supply  the 
affected  territory,  one  is  justified  in  admitting  that  this  lesion  can 
be,  in  different  eases:  (1)  of  traumatic  origin;  (2)  of  toxic  origin 
(arsenic,  CO);  (3)  of  autotoxic  origin  (diabetes);  (-1)  finally,  of 
infectious  character,  either  ordinary  (tuberculosis,  syphilis,  pneu- 
monia, grippe,  etc.),  or  sometimes  due  to  a  specific  germ.  The 
probable  existence  of  this  special  microbic  agent,  which  still  remains 
unknown,  would  serve  to  explain  the  epidemic  character,  the  pro- 
dromata,  the  febrile  and  infectious  symptoms,  the  aberrant  or  dis- 
seminated vesicles,  the  immunizing  power  against  a  new  attack 
which  is  characteristic  of  certain  zonas  and  the  so-called  zoster- 
fever  of  Landouzy  and  Erb,  or  idiopathic  zona. 

Jadassohn  points  out  that  according  to  this  interpretation,  zona 
is  the  perfect  type  of  a  .syndrome  with  an  always  identical  mor- 
phology and  pathogenesis,  but  a  variable  etiology. 

Diagnosis.  In  typical  cases,  this  is  extremely  easy;  the  eruption 
of  clustered  vesicles,  arranged  in  groups  over  one  or  more  nerve 
territories,  unilateral,  accompanied  by  pain  and  taking  a  cyclic 


ZONA  159 

course,  is  absolutely  characteristic.  Doubt  is  possible  only  in  incom- 
plete or  abortive  cases.  A  careful  examination  will  guard  against 
confusion  with  erysipelas,  eczema,  or  polymorphous  erythema.  The 
differential  diagnosis  may  occasionally  be  difficult  from  herpes  and 
the  zosteriform  eruptions. 

Herpes  is  identical  as  regards  the  eruptive  lesions,  but  is  suffi- 
ciently characterized  by  its  site,  its  frequently  bilateral  appearance, 
and  its  liability  to  recurrence.  In  the  very  unusual  case  of  a  single 
patch  of  zona,  or  in  the  presence  of  certain  bilateral  zonas,  the  differ- 
entiation may  prove  practically  impossible. 

The  zosteriform  eruptions  constitute  a  somewhat  indefinite  group, 
including  rare  and  rather  dissimilar  observations.  This  name  is 
applied  to  exanthems  constituted  by  less  numerous,  less  definitely 
grouped  and  more  voluminous  lesions  than  those  of  zona,  occupying 
the  territory  of  one  or  several  nerve  trunks,  but  only  on  a  limited 
portion  of  this  territory,  accompanied  by  sensory  disturbances, 
muscular  atrophy,  vasomotor  disturbances,  etc.  Their  essential 
characteristic  is  their  repeated  recurrence  during  several  years.  In 
one  of  my  patients,  vesicles  reappeared  five  or  six  times  a  year  at 
different  points  of  the  left  hand,  but  always  on  the  cutaneous  terri- 
tory of  the  median  nerve,  throughout  a  period  of  ten  years. 

Zosteriform  eruptions,  sometimes  called  chronic  zona  or  recurrent 
zona,  are  observed  after  traumatism  of  the  nerves,  in  peripheral 
neuritis,  in  diseases  of  the  cerebrospinal  axis,  in  syphilis,  malaria, 
etc. 

Certain  recurrent  zonas  might  be  classified  equally  well  among 
the  zosteriform  eruptions,  but  the  eruption  is  here  far  from  being 
invariably  unilateral. 

Treatment. — The  local  treatment  of  zona  must  be  as  simple  as 
possible;  avoiding  moist  dressings,  poultices,  salves,  and  ointments, 
which  only  serve  to  favor  infection,  leading  to  ulceration  and  scar- 
formation.  It  is  advisable  to  empty  the  largest  or  confluent  vesicles 
by  pricking  them  with  a  flamed  needle  and  to  apply  large  amounts 
of  bland,  aseptic  or  sterilized  powders,  in  order  to  favor  desiccation. 
Occlusive  dressings  will  relieve  the  painful  sensations. 

Ulcerative  or  gangrenous  lesions  are  treated  in  the  usual  way. 
The  sometimes  extremely  distressing  pains  of  zona  require  special 
treatment.  Analgesic  agents,  aconite,  gelsemium,  antipyrin, 
pyramidon,  exalgin,  aspirin,  are  sometimes  sufficient.  Morphin 
injections  must  be  avoided,  if  possible,  on  account  of  the  danger  of 
the  morphin  habit.  Injections  of  a  cocain  solution,  or  sterilized 
air,  along  the  course  of  the  affected  nerve,  have  been  useful  in  a  few 
cases.  Radiotherapy  and  galvanic  electricity  are  valuable  measures 
in  cases  otherwise  regarded  as  desperate. 

For  the  treatment  of  ophthalmic  zona,  the  reader  is  referred  to 
text-books  on  ophthalmology. 


CHAPTER    IX. 
PUSTULES  AND  PUSTULAR  DERMATOSES. 

The  eruptive  lesion  known  as  a  pustule  is  an  epidermal  elevation 
containing  a  purulent  fluid.  The  cavity  containing  the  pus  may  be 
situated  in  the  epidermis,  in  the  cutis,  or  in  a  follicle.  A  distinction 
is  accordingly  made  between: 

1.  Epidermic  pustules  which  may  be  superficial  when  formed 
under  the  horny  layer  (example:  impetigo);  or  deep,  when  they 
involve  the  basal  layer  of  the  mucous  body  and  therefore  leave  a 
scar  behind  them  (example:  variola,  ecthyma);  (2)  Dermic  pustules, 
which  are  rare  (example:  miliary  abscesses  of  the  newborn;  pustules 
of  tuberculosis  verrucosa);  (3)  Follicular  pustules,  which  on  the 
contrary  are  extremely  common.  The  two  last-named  varieties  will 
be  discussed  in  other  chapters. 

It  would  be  correct  and  logical  to  reserve  the  name  pustules  for 
primary  pustules,  namely,  those  in  which  the  lesion  is  suppurative 
from  the  start.  In  case  of  secondary  suppuration  of  other  eruptive 
lesions,  terms  should  be  employed  like  suppurative  vesicles,  purulent 
bullae,  or  suppurative  papules,  according  to  the  condition  present; 
but  as  this  distinction  is  not  always  practicable;  the  words  vesico- 
pustules,  papuh-pustules,  and  tubercuh-pustules,  are  in  common  use 
to  obviate  this  difficulty. 

Collections  of  pus  in  the  hypoderm  are  not  pustules,  but  abscisses 
or  gummas. 

I' ust ales  are  of  rounded,  rarely  oval  configuration,  more  or  less 
prominent,  hemispherical  or  flattened,  tense  or  flaccid,  of  a  yellowish 
white  or  grayish  color  and  surrounded  by  an  inflammatory  areola. 

Their  dimensions  are  extremely  variable,  they  may  be  punctiform, 
lenticular,  or  nummular;  often  they  are  small  at  first  and  undergo 
a  centrifugal  enlargement. 

It  is  usually  easy  to  ascertain  their  more  or  less  dee])  seat  by  means 
of  direct  examinations;  if  necessary — and  it  is  advisable  to  do  so — 
they  must  be  punctured  with  a  needle,  in  order  to  empty  the  con- 
tents, determine  the  thickness  and  constitution  of  the  roof,  the 
characteristics  of  the  floor  of  the  pustules,  etc. 

The  contents  may  be  a  more  or  less  turbid  and  yellowish  fluid, 
or  consist  of  the  creamy  thickened  substance  known  in  former  times 
as  "laudable  pus."  Examined  under  the  microscope,  it  contains 
chiefly  polynuclears  and  plasma, 


PUSTULES  AND  PUSTULAR  DERMATOSES  161 

The  pustules  do  not  persist  a  long  time,  they  terminate  by  acci- 
dental or  spontaneous  rupture,  or  by  desiccatioa.  In  both  cases, 
they  are  followed  by  a  yellow,  brown  or  black  crust,  more  or  less 
thickened  and  irregular,  covering  an  erosion,  excoriation  or  ulcera- 
tion. 

The  crusts — concerning  which  a  few  words  are  here  in  order 
from  a  general  point  of  view — are  concretions  resulting  from  the 
desiccation  of  serous  fluid,  pus,  or  blood.  Their  thickness,  regularity, 
more  or  less  hard,  greasy  or  friable  consistence,  their  color  ranging 
from  light  yellow  to  deep  black  and  their  adherence  vary  in  extremely 
wide  limits  and  are  suggestive  of  their  origin. 

Crusts  form  on  wounds,  erosions,  traumatic  or  pathological  excoria- 
tions of  all  kinds,  on  ulcerations  and  on  old  vesicles  or  pustules.  In 
case  of  vesicles  or  pustules,  the  epidermis  regenerates  itself  under- 
neath the  lesion,  extending  from  its  periphery  toward  its  center, 
eliminating  it  in  the  form  of  a  crust;  this  mechanism  is  designated 
as  eviction. 

Crusts  are  absent  from  tissue  surfaces  kept  moist  by  mutual 
contact  or  by  dressings. 

An  essential  difference  exists  between  crusts  made  up  of  scales 
which  are  disintegrating  epidermal  layers;  and  hyperkeratoses,  in 
which  coherent  horny  collections  are  formed. 

A  concretion  is  sometimes  formed  by  epidermal  layers  alternating 
with  layers  of  dried  serum  or  pus ;  these  scaly  crusts  have  a  leaf-like 
structure  and  oily  consistence;  they  are  observed  in  a  variety  of 
conditions,  notably  in  the  eczematides. 

Pustular  Dermatoses. — The  dermatoses  in  which  primary  or 
secondary  pustules  occur  are  extremely  numerous. 

1.  In  the  first  place  the  pyodermatitides  are  characterized  by 
pustules  from  the  start,  originating  on  healthy  skin  and  resulting 
from  a  cutaneous  infection  by  pus  cocci.  Only  the  impetigos  and 
ecthyma  will  be  discussed  at  this  time,  leaving  the  description  of 
the  follicular  pyodermatitides  to  the  chapter  on  the  Folliculoses. 

2.  Several  chronic  infectious  dermatoses  are  likewise  pustular  from 
the  start,  the  pathogenic  agent  being  capable  of  causing  suppuration 
by  itself  alone  (syphilis,  tuberculosis,  glanders,  mycoses,  etc.). 

3.  Some  eruptive  fevers  are  pustular  at  a  certain  stage  of  their 
course;  this  is  true  for  variola,  vaccinia  and  sometimes  varicella. 
Cutaneous  diphtheria  may  exceptionally  assume  the  complete 
appearance  of  impetigo  vulgaris.  These  diseases  need  only  be  men- 
tioned in  this  connection. 

4.  Some  artificial  dermatitides  are,  or  may  be,  pustular  from  the 
start.  Mercurial  agents,  fumes  of  tar  and  resinous  plasters  some- 
times give  rise  to  erythemas  with  small  scattered  miliary  pustules; 
thapsia,  tartrate  of  antimony,  croton  oil,  etc.,  produce  lenticular 

11 


162  PUSTULES  AND  PUSTULAR  DERMATOSES 

pustules;  oil  of  cade  and  analogous  products  sometimes  give  rise  to 
papulo-pustules.  Certain  toxidermas  of  internal  origin  are  likewise 
pustular  (iodides,  bromides).  The  question  arises  if  these  chemical 
substances  are  pyogenic  in  themselves,  or  if,  as  seems  probable, 
their  action  is  limited  to  favoring  the  penetration  and  activity 
of  the  pyococci.  The  point  has  not  yet  been  settled.  A  special 
chapter  (XXIII)  will  be  devoted  to  these  artificial  dermatitides. 

5.  There  still  remain  the  secondarily  and  accidentally  pustular 
dermatoses.  When  suppuration  supervenes  in  the  eczematous  or 
vesicular  dermatoses,  this  is  evidently  due  to  secondary  infection 
by  pyococci;  secondary  infection,  however,  has  not  been  proved 
to  be  necessary  in  the  bullous  dermatoses,  such  as  pemphigus  and 
Duhring's  disease,  which  includes  a  pustular  variety. 

The  secondary  suppurations  will  be  referred  to  in  connection 
with  each  of  the  dermatoses  in  which  they  are  met,  so  that  this 
chapter  deals  only  with  the  primary  pyodermatitides  and  a  few  chronic 
infections. 

IMPETIGO. 

The  name  impetigo  belongs  to  an  affection  characterized  by 
inoculable  and  auto-inoculable  purulent  bulla?,  appearing  rapidly 
on  the  healthy  skin,  drying  in  crusts  which  are  often  yellowish  and 
meliceric,  the  underlying  epidermis  being  simply  eroded  and  healing 
in  a  short  time  without  leaving  scars. 

Instead  of  developing  on  healthy  skin,  the  suppuration  and  crusts 
which  result  from  the  drying  of  the  pus  may  appear  on  a  wound  or 
on  a  pathological  lesion,  for  instance  eczema.  These  lesions  are  then 
said  to  be  secondarily  impetiginous,  or  better,  impetiginized. 

The  idea  of  a  microbic  external  pyococcic  origin  of  impetigo  and 
impetiginization  dates  back  nearly  to  the  first  days  of  the  discovery 
of  bacteria.  As  regards  the  responsible  bacterial  species,  investi- 
gators are  divided  into  two  schools,  some  regarding  streptococci 
and  others  staphylococci  as  the  pathogenic  agents.  An  important 
advance  was  made  when  Sabouraud  established  the  fact  that  the 
different  clinical  forms  of  impetigo  are  referable  to  different  organ- 
isms. 

There  exist  an  impetigo  streptogenes,  an  impetigo  staphylogenes, 
and  an  impetigo  vulgaris,  in  which  the  two  microbic  species  are 
associated. 

1 .  Streptococcic  Impetigo  or  Impetigo  of  Tilbury  Fox. — The  primary 
eruptive  lesion  is  a  flaccid  seropurulent  blister,  extending  peripherally. 

The  blister  from  a  hemp-seed  to  half  a  hazel-nut  in  size,  appears 
in  a  few  hours  on  a  faintly  pinkish  base.  Its  fluid  may  be  serous, 
stringy  and  at  first  hardly  turbid,  but  it  soon  becomes  cloudy  and 
is  transformed   into   sero-pus.     The  roof  of  the  blister  is  a  thin 


IMPETIGO 


1G3 


opaline  membrane,  tense  when  the  fluid  is  abundant,  wrinkled  and 
fluctuating  in  the  opposite  case. 

In  consequence  of  evaporation,  or  surface  extension,  the  bulla 
becomes  flaccid  if  it  has  not  been  so  to  begin  with.  It  may  rupture, 
allowing  its  fluid  to  escape;  or  it  may  dry  in  a  crust  in  its  center, 
while  it  enlarges  peripherally,  or  more  particularly  on  one  side, 
through  detachment  of  the  horny  epidermis.  At  this  stage  the  bulla 
is  always  surrounded  by  a  congestive  areola.  Extensive  or  serpigin- 
ous bullse  of  this  kind  are  met  with  measuring  several  centimeters 
in  diameter. 

Finally,  the  lesion  shrivels  up  to  a  yellowish  or  brownish  crust 
covering  a  red  erosion;  it  lasts  from  four  to  eight  days,  then  becomes 
detached,  leaving  behind  it  a  pinkish  or  purplish  macule,  which 
persists  a  fairly  long  time. 


Fig.  45. — Coexistence  of  impetigo  of  Tilbury  Fox  on  the  wrist,  and  impetigo  of 
Bockhardt  at  the  root  of  the  thumb,  in  a  case  of 


The  eruption  is  composed  of  a  single  bulla,  or  of  more  or  less 
numerous  bulla?,  resulting  from  simultaneous  or  successive  infections, 
or  especially  from  spontaneous  auto-inoculations.  The  bullse  are 
often  in  different  stages  of  development. 

Their  seats  of  election  are  the  face,  especially  around  the  mouth, 
the  nose  and  ears,  sometimes  in  the  beard  or  on  the  scalp;  further- 
more, on  the  extremities,  affecting  the  hands  and  fingers,  or  the  feet, 
where  they  originate  from  excoriations  caused  by  the  shoes,  etc. 

The  condition  known  as  whitlow  or  subepidermic  panaris,  ["run- 
around"]  is  nothing  more  nor  less  than  a  bulla  of  streptococcic 
impetigo,  derived  from  a  fissure  or  a  hang-nail,  and  having  a  ten- 
dency to  extend  around  the  nail. 

Other  tegumentary  regions  are  more  rarely  affected,  except  in 


1G4 


PUSTULES  AND  PUSTULAR  DERMATOSES 


ease  of  gross  neglect,  traumatism,  or  scratching.  In  scabies,  for 
example,  complication  with  the  impetigo  of  T.  Fox  is  common, 
although   less  frequent  than  staphylococcic  complications. 

In  the  impetigo  of  T.  Fox  the  glands  belonging  to  the  affected 

regions  are  usually  swollen  and  tender,  especially  when  the  eruption 
is  accompanied  by  lymphangitis;  the  absence  of  protective  dressings, 
fatigue,  overwork  and  general  debility,  favor  this  complication. 
These  cases  are  associated  with  pain,  fever,  digestive  disturbances, 
prostration;  the  local  infection  may  also  lead  to  a  grave  but  for- 
tunately rare  general  disease,  a  streptococcic  septicemia. 

In  contradistinction  to  other  forms  of  impetigo,  the  impetigo  of 
T.  Fox  shows  no  predilection  for  a  given  age  or  sex. 


A  K4HMANSKI 

Fig.  4fi. — Histology  of  impetigo  of  Tilbury  Fox.  Border  of  a  very  recent  bulla 
of  the  ear.  The  cavity  is  the  result  of  splitting  of  the  epidermis  at  the  level  of 
the  granular  layer.  The  bulla  which  is  subcorneal,  contains  a  coagulated  fibrino- 
albuminous  fluid,  detached  epithelial  cells,  and  a  small  number  of  pus  cells.  The  rete 
which  is  not  deformed  and  the  edematous  papillary  body  are  seen  to  contain  a  few 
wandering  cells  which  are  beginning  to  make  their  appearance.    X  90. 


The  affection  lasts  from  three  to  eight  days  under  suitable  treat- 
ment and  may  persist  for  weeks  or  months  under  the  opposite 
conditions,  or  when  circumstances  are  present  favoring  auto- 
inoculations. 

The  'pathological  lesion  consists  of  a  bullous  elevation  of  the  horny 
layers  by  a  fluid  composed  of  blood-plasm  and  leukocytes  in  vari- 
able proportion.  The  mucous  body  and  the  papillary  body  are 
infiltrated  with  more  or  less  numerous  wandering  cells  (Fig.  4(i). 

The  demonstration  of  the  streptococcus,  the  primary  pathogenic 
agent,  is  not  easy  in  sections;  it  is  made  by  cultures  in  ascites-broth 
in  pipettes,  according  to  Sabouraud's  method,  or  by  making  numer- 
ous streak-cultures   on    agar   slants  with   a  single   platinum   wire 


IMPETIGO 


165 


carrying  a  small  amount  of  material,  as  recommended  by  Lewan- 
dowsky. 

2.  Impetigo  Vulgaris. — This  is  the  most  frequent  form  of  impetigo 
and  is  chiefly  observed  in  children  of  all  ages,  especially  from  two  to 
seven  years,  or  in  adults  with  a  delicate  skin.  It  is  highly  contagious 
and  of  polymicrobic  origin. 

It  was  formerly  considered  as  the  typical  impetigo  whose  chief 
characteristic  was  said  to  be  the  thick,  extensive,  coarse,  yellow 
crusts,  which  were  described  as  meliceric  on  account  of  their  resemb- 
ling dried  honey.  The  popular  term  of  milk  crusts  is  applied  to 
this  impetigo  as  well  as  to  impetiginized  infantile  eczemas  and 
seborrheal  crusts,  etc. 


Fig.  47. — Impetigo  vulgaris  of  the  face  in  a  child  aged  two  years. 


A  crust  can  never  be  characteristic  of  a  dermatosis  as  it  is  always 
merely  a  secondary  lesion.  On  closely  following  a  case  of  impetigo 
vulgaris,  the  initial  lesion  will  usually  be  found  to  be  a  bulla  of  T. 
Fox  impetigo;  this  rapidly  becomes  purulent,  dries  to  a  crust  at  its 
center  while  it  extends  at  its  periphery  and  in  this  way  gives  rise  to 
circinate  crusted  lesions.  At  the  circumference  appear  either  similar 
lesions,  or  staphylococcic  pustules,  such  as  will  be  described  further 
on.     The  glands  are  usually  enlarged. 


100 


PT'STl'LES   AM)   PUSTULAR   DER MATOSES 


The  eruption  often  lakes  its  origin  near  the  nostrils,  following 
coryza;  near  the  mouth,  following  fissures  of  the  lips  or  "perleche" 
(Fig.  17  i,  near  the  eyelids  in  the  case  of  conjunctivitis;  on  the 
cars,  in  case  of  suppurative  otitis;  in  the  occipital  region  of  the 
scalp  in  children  and  women  having  head  lice;  on  the  beard; 
where  it  is  inoculated  by  means  of  the  razor  (Fig.  48).  [In  my 
experience  impetigo  in  children  is  almost  invariably  associated  with 
pediculosis  capitis.] 


4 

K 

V 

Fig.    IS. — Impetigo  vulgaris,  derived  from  inoculation  with  a  razor. 


Impetigo  larvalis  is  the  term  applied  to  an  eruption  which  covers 
the  fa.ee  like  a  mask;  impetigo  granulata  affects  the  seal])  or  the 
beard,  giving  rise  to  crusts  whose  fragments  adhere  to  the  hairs. 
Other  varieties  have  been  described  as  impetigo  sparsa,  figurata, 
etc. 

It  is  not  nearly  so  important  to  fit  the  exact  descriptive  term  to  the 
objective  appearance  as  to  determine  if  the  impetigo  is  primary  or 
secondary  in  character.  As  a  matter  of  fact,  it  may  point  the  way  to 
an  infection  of  the  mucous  membranes  or  body  orifices  as  stated 
above,  or  complicate  an  eczema,,  a  hum,  or  some  traumatic  der- 
matitis, scabies,  lupus  (  Fig.  169),  syphilides, etc.  These impetiginized 


IMPETIGO  167 

eruptions  are  sometimes  not  clearly  recognized  unti1  after  several 
days  of  treatment. 

The  microbes  of  impetigo  vulgaris  may  become  implanted  and 
vegetate  wherever  they  find  a  point  of  entrance. 

The  term  impetigo  contagiosa  has  no  special  significance  and 
applies  to  cases  where  genuine  epidemics  are  observed  in  families 
or  schools. 

Impetigo  has  a  marked  tendency  to  recurrences  which  are  ex- 
plained by  the  persistence  of  virulent  pyococci  in  the  lesions,  called 
by  Sabouraud  the  chronic  remains  of  impetigo,  such  as  redness  and 
crust-formation  behind  the  ears,  around  the  nostrils,  perleche, 
blepharitis  and  styes,  and  even  pityriasis  simplex  (dry  seborrhea). 
These  chronic  infections  and  the  adenopathies  dependent  upon 
them  enter  into  the  clinical  picture  of  scrofula. 

Impetigo  of  the  Mucous  Membranes. — When  astride  the  free 
border  of  the  lips,  impetigo  is  crusted  in  its  cutaneous  portion  and 
diphtheroid  in  its  mucous  portion.  Sevestre  and  Gaston  have 
described  an  impetiginous  stomatitis,  the  characteristics  of  which 
are  as  follows:  Diphtheroid  spots  of  a  yellowish  white  color; 
imbedded  and  incorporated  in  the  epithelium,  scattered  over  the 
mucosa  of  the  lips,  the  cheeks,  sometimes  on  the  tongue  and  palate, 
never  on  the  isthmus  of  the  pharynx  or  in  the  throat;  usually, 
ulceration  of  the  alveolar  margin;  a  low  degree  of  contagiousness; 
ordinarily  associated  with  impetigo  of  the  face.  Failure  to  recognize 
this  affection  may  result  in  the  most  annoying  errors  in  diagnosis. 

Certain  coryzas,  pyococcal  blepharoconjunctivitis,  even  phlyc- 
tenular conjunctivitis,  may,  strictly  speaking,  be  interpreted  as 
impetigo  of  mucous  membranes. 

3.  Staphylococcic  Impetigo,  or  Impetigo  of  Bockhardt. — This  is  char- 
acterized by  a  primary  pustule,  containing  yellowish  creamy  pus, 
often  centered  by  a  hair  and  surrounded  by  a  congestive  areola. 
The  lesion  has  the  size  of  a  pin-head  to  that  of  a  large  lentil;  the 
pus  collects  under  the  horny  laver,  elevating  and  distending  it 
(Fig.  49).     _ 

A  perifollicular  seat  is  common  but  not  constant  and  Bockhardt's 
impetigo  has  so  many  points  of  contact  with  impetigo  vulgaris  that 
it  must  be  grouped  with  the  latter  rather  than  with  the  folliculitis. 
The  pustules  are  usually  multiple,  often  very  numerous  and  are 
grouped  in  one  or  more  regions  whence  they  may  spread.  The 
eruption  has  no  preference  for  special  parts  of  the  body,  but  develops 
at  any  point  where  the  horny  layers  have  ceased  to  oppose  an  efficient 
barrier  against  the  penetration  of  the  pyococci.  This  occurs  in 
cases  of  traumatism,  scabies,  chemical  dermatitis,  or  epidermal 
maceration  through  the  application  of  a  simple  poultice  or  plaster. 
Preexisting   suppurations,  dirt,  pruritus   and   neglect,    constitute 


168  PUSTULES  AND  PUSTULAR  DERMATOSES 

conditions  favorable  to  its  development.    A  youthful  age,  lymphat- 
ism,  overexertion,  etc.,  seem  to  act  as  predisposing  factors. 

The  pustules  of  staphylococcic  impetigo  appear  in  a  few  hours, 
being  more  resistant  than  those  of  the  preceding  forms;  they  rupture 
late  or  accidentally.  The  pus  is  then  thickened  into  yellow  crusts. 
Unopened  pustules  shrivel  up  first  in  the  center  and  are  cast  off"  by 
eviction. 

Bockhardt's  impetigo  is  accordinglv  merely  one  of  the  elementary 
forms  of  cutaneous  staphylococcia,  the  most  superficial  and  most 
benign  type  of  the  disease.  There  exist  intermediary  forms  between 
the  impetigo  of  Bockhardt  and  the  more  or  less  deep  folliculitides 
(Plate  II).  Combinations  with  other  forms  of  staphylococcia 
frequently  occur. 


•  i ... 


Fig.  49. — Histology  of  the  pustule  of  Bockhardt's  impetigo.  The  cavity  of  the 
pustule  is  situated  within  the  rete;  its  roof  is  formed  by  the  horny  layer,  doubled  in 
places  by  the  granular  layer;  its  floor  is  represented  by  the  lower  strata  of  the  rete, 
which  are  seen  to  be  crowded  and  flattened.  The  oblique  section  of  two  downy 
hairs  may  be  seen  floating  in  the  purulent  contents  of  the  pustule.      X  60. 

A  bullous  form  of  impetigo,  generally  known  under  the  name  of 
epidemic  pemphigus  of  the  newborn  will  be  discussed  further  on  p.  178. 

The  affection  described  under  the  name  of  infantile  vacciniform 
dermatitis  by  Hallopeau,  vacciniform  herpes,  by  Founder,  is  probably 
merely  a  variety  of  impetigo.  It  appears  in  the  form  of  erythematous 
spots,  the  epidermis  of  which  is  rapidly  raised  by  a  turbid  fluid, 
with  central  umbilication.  It  is  observed  in  neglected  infants, 
especially  around  the  ano-genital  region.  The  eruption  may  simu- 
late varicella. 

Treatment.  Every  practitioner  should  know  how  to  treat  impetigo. 
Whether  it  be  primary  or  secondary,  the  treatment  is  the  same,  but 
in  the  latter  case,  after  the  complication  has  been  removed,  the 
original  dermatosis  will  require  attention. 

In  the  first  place,  the  treatment  must  be  local.  A  fundamental 
rule  is  to  get  rid  at  once  of  all  crusts  or  active  inflammation  that 


ECTHYMA  169 

may  be  present.  This  will  be  accomplished  in  a  day  or  two  by  means 
of  moist  softening  or  slightly  antiseptic  dressings,  sprays  or  starchy 
poultices,  to  be  applied  cold.  At  each  dressing,  at  least  three  times 
in  twenty-four  hours,  antiseptic  or  astringent  lotions  must  be  applied ; 
the  solution  which  for  some  time  has  achieved,  or  rather  resumed 
general  and  well  deserved  favor  is  Alibour  water,  the  formula  of 
which  dates  back  to  the  reign  of  Henri  IV.  As  soon  as  the  surfaces 
are  cleansed,  pastes  or  salves  made  with  boric  acid,  camphor,  white 
precipitate  and  especially  yellow  precipitate  are  indicated.  A  mer- 
curial plaster  is  serviceable  for  the  isolation  of  scattered  lesions  of 
impetigo.  Camphorated  lotions  or  ichthyol  pastes  help  to  prevent 
recurrences. 

Internal  treatment,  contrary  to  a  commonly  held  view,  is  by  no 
means  indispensable,  and  must  never  be  considered  as  sufficient  by 
itself  alone.  It  may  be  necessary  sometimes  to  prescribe  cod-liver 
oil,  iron  iodide,  arsenic,  or  the  ferments  and  yeasts.  Dietetic 
measures,  residence  by  the  seaside,  or  mineral  springs,  influence 
only  the  general  condition. 

ECTHYMA. 

The  meaning  of  the  term  ecthyma  has  undergone  some  slight 
changes,  according  to  different  authors  and  at  different  times,  so 
that  it  is  somewhat  difficult  to  separate  ecthyma  from  the  impetigos, 
from  rupia  of  the  older  writers  and  from  ulcers  of  the  skin. 

Ecthyma  actually  represents  a  pustulo-idcerative  pyodermatitis; 
namely,  a  microbic  dermatitis  of  external  origin (XXVI) like  impetigo, 
beginning  like  the  latter  with  a  pustule,  but  differing  from  it  by  the 
greater  dimensions  of  its  lesions  and  especially  by  their  ulcerative 
character.  The  ulceration  is  frequently  covered  by  a  crust,  which 
may  be  rupioid.  Ecthyma  always  leaves  a  scar  behind  it.  Like 
all  other  pyodermatitides,  it  is  inoculable  and  auto-inoculable.  Its 
special  clinical  characteristics  are  referable  to  a  peculiar  virulence 
of  its  pathogenic  agents,  or  to  a  deeper  inoculation  of  these  agents, 
favored  by  some  tissue  lesion  or  preliminary  affection,  or  finally 
to  the  soil  on  which  it  develops. 

When  the  mode  of  formation  of  an  ecthyma  lesion  can  be  watched, 
it  is  seen  to  begin  with  a  pustule,  usually  flattened  and  with  turbed 
contents,  like  the  impetigo  of  T.  Fox,  more  rarely  tense  and  con- 
taining a  creamy  pus,  like  the  impetigo  of  Bockhardt. 

This  pustule,  having  very  rapidly  reached  nummular  dimensions, 
shrivels  up  into  a  more  or  less  thickened,  yellowish  or  brown, 
adherent  crust,  which  is  flattened  or  protuberant,  sometimes 
ostreaceous,  surrounded  at  first  by  a  bullous  collar  and  always  by 
a  congestive  halo.    When  this  crust  falls  off  or  is  removed  by  means 


170  PUSTULES  AND  PUSTULAR  DERMATOSES 

of  the  dressings,  it  is  seen  to  cover  a  rounded  or  oval  ulceration, 
more  or  less  deeply  encroaching  upon  the  derma.  Its  borders  are 
regular  and  clean-cut;  the  floor  is  red  or  pultaceous,  sloping  toward 
the  center  in  the  stage  of  advance,  granulating  in  the  stage  of  repair; 
the  secretion  consists  of  viscid  or  clotted  brownish  and  blood-tinged 
pus;  the  base  is  not  indurated,  but  sometimes  diffusely  edematous. 

After  lasting  two  or  three  weeks  in  favorable  cases,  but  much 
longer  under  bad  conditions,  the  ulceration  heals  through  granula- 
tion and  cicatrization;  the  scars  are  often  pigmented  at  their  border. 

Glandular  enlargement,  lymphangitis,  phlebitis,  abscesses,  are  rare 
complications. 

The  lesions  are  usually  multiple,  rarely  very  numerous  and,  as  a 
rule,  of  different  ages,  having  originated  from  successive  auto- 
inoculations. 


Fig.  50. —  Eethyma  oi  the  leg.     The  lesions  have  been  deprived  of  their  crusts  and 
cleansed  by  means  of  moist  dressings. 

Ecthyma  has  its  .scat  of  election  on  the  lower  limbs  (Fig.  50);  the 
buttocks  and  the  back  are  less  frequently  affected,  the  part  played 
by  congestion  and  circulatory  stasis  is  therefore  very  evident. 

Ecthyma  is  usually  observed  only  during  the  first  half  of  life;  it 
affects  overstrained,  weakened,  scrofulous,  diabetic,  varicose,  or 
alcoholic  subjects;  not  uncommonly,  it  is  induced  by  scratching 
due  to  uncleanliness,  or  by  scabies  and  lice.  Ecthyma  has  figured 
to  a  great  extent  among  the  soldiers  in  the  trenches. 

There  are  no  valid  reasons  for  distinguishing  a  cachectic  ecthyma, 
;i  scrofulous  ecthyma,  etc.,  nor  is  it  correct  to  describe  as  scabies- 
ecthyma  all  the  pyodermatitides  complicating  the  itch.  The  anti- 
quated terms  of  syphilitic  ecthyma  and  syphilitic  rwpia,  to  designate 
ulcerative  syphilides,  are  altogether  objectionable. 


ECTHYMA 


171 


In  the  presence  of  unfavorable  nutritional  conditions  and  local 
circulatory  disturbances,  an  ecthyma  pustule  may  become  the 
starting-point  of  a  leg-ulcer. 

The  pathological  anatomy  of  ecthyma,  in  the  ulcerative  stage, 
shows  a  deep  and  remarkably  distinct  ulcer,  bordered  by  a  thin 
layer  of  leukocyte  infiltration;  apparently  resulting  from  molecular 
disintegration  and  not  from  sloughing.  The  pus  contains  tissue- 
debris,  elastic  fibers,  altered  red  corpuscles,  and  various  cocci. 

Ecthyma  is  ascribed  by  authors  either  to  the  streptococcus  or  to 
a  microbic  association.  Vidal's  statement  that  experimental  inocu- 
lation of  ecthyma-pus  will  produce  this  dermatosis,  but  no  other  pyo- 
dermatitides,  is  not  strictly  correct;  however,  the  ecthyma-eruption 


Fig.  51. — Erythema  terebrans  of  the  back  in  a  child  a,ged  two  and  a  half  years. 


is  not  infrequently  pure  and  is  not  associated  with  other  pyococcic 
manifestations.  According  to  recent  investigations  of  Lewandowsky 
ecthyma  seems  to  be  a  simple  streptococcia,  closely  related  to  the 
impetigo  of  T.  Fox  and  with  a  slight  tendency  to  become  secondarily 
infected. 

The  name  ecthyma  terebrans  is  applied  to  a  pustulo-ulcerative 
eruption  in  children,  rare  and  rather  obstinate,  occupying  the 
buttocks,  thighs,  and  back  progressing  by  contiguity,  in  the  form 
of  lenticular,  sometimes  vacciniform  or  even  gangrenous  pustules 
(gangrenous  varicella  of  English  and  American  writers).  These 
pustules  become  confluent  and  give  rise  to  enormous  polycyclic 


172  PUSTULES  AND  PUSTULAR  DERMATOSES 

ulcerations,  with  festooned  margins,  a  grayish  floor  and  dusky  cir- 
cumference, leaving  honey-combed  cicatrices  (Fig.  51).  This  grave 
eruption  lias  been  observed  especially  in  weakly  newborn  infants 
suffering  from  diarrhea  (Neumann's  ecthyma  of  cachectics) ;  excep- 
tionally also  in  older  children  and  even  in  adults.  According  to 
Bosellini  and  others,  the  affection  is  due  to  the  bacillus  pyocyaneus. 

The  treatment  of  any  ecthyma  of  the  lower  limbs  requires  rest,  in 
bed,  moist  applications  to  loosen  the  crusts,  followed  by  lotions  of 
Alibour  water  or  peroxide  water;  the  ulcers  are  then  dressed  with  a 
salve  or  paste  of  yellow  oxide,  or  an  absorbent  or  antiseptic  powder 
may  be  used,  such  as  dermatol,  aristol,  etc.  Touching  with  a  silver 
nitrate  solution  may  prove  useful.  During  the  stage  of  repair,  the 
ulcerations  are  advantageously  covered  with  red  oxide  ointment  or 
balsam  of  Peru. 

General  treatment  is  not  usually  necessary;  regulation  of  the 
patient's  hygiene  will  suffice. 

PUSTULES  OF  THE  INFECTIOUS  CHRONIC  DERMATOSES. 

Syphilis,  tuberculosis,  glanders  and  certain  mycoses  and  tropical 
diseases  may  give  rise  to  pustular  .syndromes. 

Syphilis. — There  exist  syphilides  which  are  only  apparently 
pustular;  no  drop  of  pus  can  be  obtained  by  puncturing  them  with 
a  needle.  Such  syphilides  are  known  as  papulo-crusted  or  impeti- 
ginous syphilides.  They  are  generally  mixed  in  with  a  crop  of 
lenticular  papules,  of  which  they  are  merely  a  variety;  or  they  may 
predominate  in  a  given  eruption. 

The  more  or  less  profuse  eruption  is  irregularly  scattered  over  the 
trunk,  limbs,  face  and  scalp;  it  consists  of  round  lenticular  crusts, 
brownish-yellow,  swollen,  slightly  adherent,  sometimes  exuberant, 
ostreaceous  or  rupioid  (see  Fig.  94),  which  cover  a  papule  with  a 
smooth  moist  surface,  instead  of  an  ulceration,  as  one  might  be  led 
to  believe. 

Precocious  malignant  syphilides  of  the  ecthymatoustype  begin,  before 
undergoing  ulceration,  with  a  large  papule  the  epidermis  of  which  is 
raised  by  pus;  this  hardens  into  a  crust;  under  this  crust  and  at  its 
periphery  the  ulceration  develops  and  progresses. 

Tuberculo-crusted  syphilides,  which  are  apt  to  be  circinate,  are  only 
transitorily  pustular;  they  belong  rather  to  the  tuberculo-ulcerative 
eruptions. 

Tuberculosis. — Tuberculous  ulcers  begin  as  very  small  papulo- 
pustules which  open  and  coalesce.  In  tuberculosis  verrucosa,  deep 
pustules  are  almost  regularly  seen,  the  contents  of  which  can  be 
squeezed  out  by  compressing  the  vegetating  patch  between  the 
fingers. 


PUSTULES  OF  INFECTIOUS  CHRONIC  DERMATOSES     173 

There  exists  a  form  of  lupus  exedens  which  is  entitled  to  the  name 
of  pustular  lupus. 

It  is  especially  important  to  keep  in  mind  the  very  frequent 
occurrence  of  impetiginous  changes  in  eroded  lesions  of  lupus; 
fungoid  tubercles,  open  scrofulous  gummas,  or  atypical  tuber- 
culous ulcers  becoming  covered  with  yellow  or  brownish  crusts. 
A  diagnosis  of  impetigo  or  ecthyma  must  be  carefully  excluded  in 
such  cases.  In  the  absence  of  information  regarding  the  develop- 
ment, it  suffices  to  detach  or  otherwise  remove  the  crusts,  to  bring 
into  view  the  grave  underlying  lesions. 

Papulo-necrotic  tuberculides  are  genuine  pustules  at  a  certain  stage 
of  their  development.  They  are  generally  recognized  by  their  very 
peculiar  course  and  sometimes  by  their  topographical  distribution. 

Glanders. — One  of  the  clinical  features  of  acute  glanders  consists 
in  a  pustular  eruption  resembling  that  of  smallpox.  The  round, 
non-umbilicated  pustules  form  rapidly,  occupying  especially  the 
face,  the  mucous  membranes  and  the  limbs;  they  rupture  later  on, 
leaving  extensive  ulcerations.  The  general  symptoms  suggest  the 
diagnosis  which  must  be  confirmed  by  bacteriological  methods. 

The  mycoses  (sporotrichosis,  etc.),  Leishmaniasis  (Biskra  boil  or 
button)  and  verruga  Peruviana  may  give  rise  to  pustules  at  their 
onset,  or  in  the  course  of  the  disease  (XXIX). 


CHAPTER   X. 
BULLAE  AND  BULLOUS  DERMATOSES. 

BuiJLffi  or  phlyctenes  (blebs)  are  eircumscribed  elevations  of  the 
epidermis  containing  an  ordinarily  clear  and  serous,  sometimes 
turbid  or  hemorrhagic  fluid;  when  the  fluid  consists  of  pus,  the  lesion 
becomes  a  purulent  bulla. 

Hulhe  differ  from  vesicles  by  their  generally  larger  size  as  well  as 
by  their  structure  and  mode  of  formation.  Their  shape  is  round  or 
oval  and  their  size  varies  from  that  of  a  pin-head  to  that  of  a  hen's 
egg  or  larger;  their  surface  is  tense  or  flaccid.  They  terminate 
through  rupture,  suppuration,  or  simple  desiccation;  in  all  these 
cases,  they  are  followed  by  a  crust  of  variable  color  and  thickness 
according  to  the  character  of  the  exudate,  covering  a  more  or  less 
dee])  erosion.  The  crust  becomes  detached  in  five  to  fifteen  days, 
leaving  almost  invariably  a  temporary  red  or  brownish  macule  in 
its  place. 

Blebs  or  bullae  do  not  result  from  a  progressive  process,  like  vesicles, 
but  from  a  genuine  splitting  of  the  epidermis.  Their  cavity  is  there- 
fore unilocular  from  the  start;  when  the  fluid  contents  have  been 
emptied,  through  pricking  or  tearing  the  bulla,  it  collapses  entirely. 

Two  processes  are  concerned  separately  or  jointly  in  the  formation 
of  bulla?.  Most  frequently  they  follow  a  local  dermic  edema,  the 
edematous  fluid  under  high  pressure  filtering  through  the  Mal- 
pighian  layer,  until  it  is  arrested  by  the  horny  layer  which  it  raises 
by  accumulating  below  it.  This  results  in  the  production  of  a 
superficial  or  .subcorneal  bulla  (Figs.  46  and  58). 

In  other  cases,  the  still  more  sudden  rush  of  fluid  detaches  the 
epithelium  as  a  whole,  giving  rise  to  a  deep  or  subepithelial  bulla 
(Fig.  56.) 

In  ease  of  the  second  mode  of  bleb-formation,  the  mutual  cohesion 
of  the  cells  of  the  mucous  body  is  pathologically  diminished;  the 
intercellular  Glaments  have  lost  their  resistance;  they  separate  under 
the  influence  of  the  slightest  excess  of  pressure  of  the  intercellular 
plasma.  This  abnormal  condition  is  designated  as  acantholysis, 
after  Auspitz,  and  the  resulting  bullae  are  known  as  arantholi/tic 
bulla: 

Bullous  Dermatoses.  -The  group  of  bullous  dermatoses  is  very 
extensive  and   very   complex.     The  older  writers  interpreted  all 


ACCIDENTALLY  BULLOUS  DERMATOSES  175 

bullous  eruptions  as  pemphigus,  a  circumstance  which  resulted 
in  extraordinary  and  persistent  confusion.  This  designation  is  now 
reserved  for  a  small  minority  of  these  cases.  The  following  eruptions 
do  not  belong  under  the  heading  of  pemphigus: 

Traumatic  bulla',  or  blisters,  produced  by  strong  pressure  [or 
friction] ;  and  those  which  result  from  burns,  or  from  the  action  of 
caustics  and  vesicants.  These  are  artificial  external  dermatitides 
of  bullous  form  and  will  be  discussed  further  on  (XXIII). 

Bullae,  occurring  as  epiphenomena  in  the  course  of  definite  nervous 
or  infectious  diseases,  such  as  syringomyelia,  leprosy,  purulent 
infection,  etc. 

Accidentally  bullous  dermatoses,  such  as  erysipelas,  eczema, 
dysidrosis,  ichthyosiform  hyperkeratosis;  mention  must  be  made 
of  bullous  urticaria,  bullous  polymorphous  erythema  or  hydroa, 
bullous  syphilides  and  bullous  toxicodermas  of  internal  origin. 

External  microbic  bullous  eruptions,  which  according  to  Unna  are 
all  entitled  to  the  name  of  impetigo.  Although  it  remains  doubtful 
if  certain  pathological  varieties  should  be  grouped  under  this  heading 
rather  than  with  acute  pemphigus,  this  seems  to  be  justifiable  as 
regards  the  so-called  epidemic  pemphigus  of  the  newborn  and  of 
adults,  which  is  really  a  bullous  impetigo. 

Eliminating  these  forms  there  are  left  some  essentially  bullous 
affections,  of  undetermined  but  decidedly  variable  type,  which  are 
designated  as  pemphigus,  and  include:  (1)  Pemphigus  acutus 
febrilis  gravis.  (2)  Recurrent  polymorphous  pemphigus,  or  Duhring's 
dermatitis;  (3)  Pemphigus  chronicus;  (4)  Pemphigus  foliaceous; 
(5)  Pemphigus  vegetans;  (6)  Pemphigus  congenitalis.  So-called 
pemphigus  hystericus  will  later  be  considered  in  a  few  lines. 

Accidentally  Bullous  Dermatoses. — Some  of  these  require  special 
mention  on  account  of  the  difficulties  of  diagnosis  and  interpreta- 
tion which  they  may  occasion. 

Bullous  Urticaria. — This  is  a  rare  variety  of  urticaria  in  which  all 
or  some  of  the  lesions  become  crowned  with  a  bullous  prominence, 
followed  by  a  crust.  The  eruption  may  be  chronic  or  recurrent. 
In  view  of  the  pruritus  and  the  erythematous  base  of  the  bullae,  this 
affection  may  be  confused  with  Duhring's  dermatitis,  from  which 
it  is  distinguished  by  its  irregular  distribution  and  the  absence  of 
true  polymorphism,  each  bulla  originating  on  .in  urticarial  wheal. 
Sometimes,  it  is  possible  to  demonstrate  a  tendency  to  urticaria  in 
the  patients. 

Bullous  Polymorphous  Erythema  or  Hydroa. — In  certain  cases  of 
polymorphous  erythema,  localize  1  as  usual  on  the  back  of  the  hands, 
on  the  wrists,  elbows,  knees,  on  the  face  and  especially  on  the 
forehead,  etc.  (Fig.  52),  some  lesions  or  most  of  them  may  become 
the  seat  of  vesicles  or  of  tense  bullae  which  when  pricked  with  a 


176 


BULLM  AND  BULLOUS  DERMATOSES 


pin  void  a  lemon-yellow  or  reddish-fluid.  The  bullae  occupy  the 
entire  surface  of  the  papular  elevations  or  only  their  center;  some- 
times they  are  situated  at  the  periphery. 


Fig.  52.— Erythema  bullosum;  first  attack,  in  a  gir]  aged  eleven  years.  (The  buccal 
mucosa  were  affected  a1  several  points. 


I  ,,,.  53      Erythema  bullosum  of  the  variety  hydroa  vesiculareof  Bazin,  or  herpes  iris 
of  Bateman. 


The  name  of  Bazin's  hydroa,  or  herpes  iris  of  Bateman,  is  applied 
to  a  variety  in  which  the  lesions,  consisting  of  a  small  bulla  or  central 
crust,  surrounded  by  a  bright  red  or  purplish  disk,  a  vesiculo- 
bullous  circlet  and  narrow  erythematous  border,  present  a  striking 
cockade-like  arrangement  (Fig.  53). 


BULLOUS   TOXICODERMAS  111 

The  eruption  often  affects  also  the  lips,  the  mouth,  the  tongue, 
the  pharynx  and  the  other  mucous  membranes. 

Hydroa  biiccale,  characterized  by  bullous  elevations  which  are 
rapidly  replaced  by  very  painful  nummular  deep  red  or  diphtheroid 
erosions,  simulates  and  is  sometimes  mistaken  for  mucous  patches. 
In  exceptional  cases  it  may  be  accompanied  by  fever  and  infectious 
symptoms,  with  severe  visceral  complications. 

Polymorphous  bullous  erythema  usually  lasts  from  two  to  five 
weeks;  it  may  be  prolonged  beyond  that  time  by  successive  erup- 
tions, or  it  may  recur  at  variable  intervals  in  a  number  of  attacks. 
This  tendency  to  relapse  and  the  unusual  severity  of  the  sensations 
of  itching  and  heat,  in  some  cases  result  in  so  close  a  resemblance 
to  Duhring's  disease  as  to  render  the  diagnosis  necessarily  doubtful. 

Bullous  Syphilides. — The  eruption  known  under  the  name  of 
syphilitic  pemphigus  is  met  with  on  the  palmar  and  plantar  regions 
of  newborn  children  with  congenital  syphilis.  It  consists  of  papular 
lesions  of  a  purplish  or  coppery  hue,  discrete  or  confluent,  the  epi- 
dermis of  which  is  raised  by  a  turbid  or  blood-stained  fluid;  the 
dimensions  of  the  bullae  vary  from  those  of  a  hempseed  to  those  of  a 
large  bean,  but  confluence  in  extensive  patches  may  occur. 

In  two  or  three  days,  these  bullae  dry  into  crusts,  covering  an 
ulceration.  Their  fluid  contents  and  especially  the  fluid  obtained 
by  scraping  their  floor,  contain  enormous  numbers  of  spirochetes. 
It  is  exceptional  for  the  eruption  to  become  generalized  under  the 
same  form;  but  a  few  aberrant  bullae,  or  syphilides  of  another  type, 
may  be  found  in  other  portions  of  the  body. 

This  eruption,  the  only  syphilide  assuming  a  bullous  form,  appears 
almost  exclusively  at  the  time  of  birth,  a  few  days  before  or  after. 
It  is  pathognomonic. 

Bullous  Toxicodermas. — Aniipyrin  bulla?  represent  a  transforma- 
tion of  the  erythematous  patches  produced  by  antipyrin  in  some 
individuals  (Fig.  145).  They  originate  abruptly  in  any  region, 
especially  the  genitals  and  the  mouth,  reappearing  with  each 
repeated  administration  of  the  drug  and  leave  a  brown  discoloration. 

Iododerma  bulbsum  is  a  rare  affection  produced  by  potassium  iodide 
or  its  congeners;  the  lesions  may  be  clear,  distinctly  pemphigoid  bullae, 
of  rapid  development,  located  especially  on  the  neck  or  in  the  folds 
(Fig.  146);  or  the  condition  may  consist  of  very  rapidly  purulent 
and  extensive  bullae,  the  center  of  which  becomes  fungoid  arid 
crusted,  situated  in  very  variable  numbers  on  the  face,  the  mouth, 
the  limbs  or  the  trunk;  they  suggest  the  fungoid  syphilides  or  more 
particularly  pemphigus  vegetans.  This  eruption  may  persist  during 
several  weeks,  especially  if  the  medication  is  continued. 

Bromides,  arsenic,  etc.,  are  likewise    capable    of    causing   the' 
appearance  of  blisters. 
12 


178  BULLJE  AND  BULLOUS  DERMATOSES 

BULLOUS  IMPETIGOS. 

The  impetigos  are  pyodermatitides  the  eruptive  lesion  of  which 
is  a  pustule  or  a  purulent  bulla;  they  are  all  more  or  less  contagious. 

A  somewhat  distinct  bullous  type  is  generally  described  under  the 
name  of  epidemic  pemphigus  of  the  newborn.  It  is  encountered  in 
nursing  infants,  in  asylums,  hospitals,  or  even  in  families— more 
rarely  in  adults — in  the  form  of  an  acute  eruption  of  clear  tense  hemi- 
spherical bulhe,  the  size  of  a  lentil  to  that  of  a  nut;  from  one  to  about 
thirty  in  number.  They  occur  in  the  folds  of  the  neck,  trunk  and 
limbs,  rarely  on  the  face,  but  are  never  encountered  in  the  palmar 
and  plantar  regions. 

These  bulla?  supervene  in  healthy  or  in  marasmic  children,  in 
successive  crops,  in  the  form  of  red  spots  which  very  rapidly  become 
blisters;  at  the  end  of  a  few  hours  the  bulla  ruptures  and  the  thin 
crust  falls  off  in  a  few  days.  Recovery  is  the  rule;  exceptionally ,  in 
weakened  patients,  symptoms  of  severe  general  infection  have  been 
noted. 


3  i» 


Fn;.   .54. — Impetigo  bullosum  in  a  child  aged  sixteen  months. 

This  affection  is  highly  contagious.  Vida]  has  shown  that  it  is 
possible  to  inoculate  and  auto-inoculate  the  fluid  of  the  bulhe.  It 
contains,  according  to  Peter,  the  Staphylococcus  aureus,  some  albus 
and  a  special  diplococcus  which  is  by  several  authors  considered  the 
cause  of  the  disease;  perhaps,  in  addition,  a  streptococcus.  The 
Staphylococcus  aureus  is  regarded  as  the  real  pathogenic  agent  by 
Dohi  and  Jadassohn. 

Bullous  impetigo  is  sometimes  observed  also  in  older  children 
(infantile  pemphigoid  of  Jadassohn)  in  combination  witli  various 
pyodermatitides  (Fig.  54). 

Confusion  must  be  avoided  with  varicella,  generalized  vaccinia, 
impetigo  vulgaris  and  the  bullous  syphilides.    However,  the  features 


RECURRENT  PEMPHIGUS  OR  DUHRING'S  DISEASE      179 

of  these  various  eruptions  are  usually  sufficiently  distinct  to  guard 
against  errors  in  diagnosis. 

The  treatment  consists  in  extreme  cleanliness,  absolute  hygiene 
and  isolation  of  the  patient.  Locally,  washing  with  Alibour  water 
will  suffice,  and  dressings  with  a  bland  powder,  an  oil  and  lime 
liniment,  or  yellow  precipitate  salve. 

PEMPHIGUS  ACUTUS  FEBRILIS  GRAVIS. 

This  is  a  systemic  infectious  disease,  with  a  bullous  eruption, 
studied  by  Nodet  (1880),  George  Pernet  (1895-1896)  and  Brocq; 
it  affects  almost  exclusively  butchers,  sausage-makers,  pork- 
choppers,  tanners,  cooks,  etc.,  namely  persons  who  handle  dead 
animals.  The  infection  usually  follows  upon  some  injury  of  the  hand, 
manifesting  itself,  abruptly  by  chills,  prostration,  vomiting  or  diar- 
rhea, delirium  or  depression  and  a  temperature  of  40°  (104°).  The 
eruption  appears  twenty-four  to  forty-eight  hours  later,  in  the  form 
of  tense  bullae  with  yellowish  or  hemorrhagic  contents;  originating 
on  red  spots  and  almost  invariably  undergoing  rupture.  It  occupies 
the  neck,  the  chest,  the  limbs  or  the  entire  body;  discrete  at  first,  it 
soon  becomes  confluent  and  may  involve  the  mucous  membranes. 
Death  results  in  over  three-fourths  of  the  cases,  at  the  end  of  one 
to  three  weeks,  under  typhoid  symptoms,  albuminuria,  various 
congestions,  etc.  Recovery  takes  place  through  gradual  subsidence 
of  the  symptoms  in  three  to  six  weeks. 

The  anatomical  lesions  of  acute  pemphigus  and  its  pathogenic 
microbe  are  unknown.  The  condition  evidently  represents  a 
variety  of  septicemia. 

The  indications  are  to  combat  the  infection  by  means  of  quinine, 
collargol,  serum  injections  and  intestinal  irrigation,  and  to  support 
the  organism  by  all  possible  means.  Moist  or  oily  dressings,  cotton 
wraps,  and  so  forth  serve  to  relieve  the  burning  sensation  which  is 
often  extremely  distressing. 

RECURRENT  PEMPHIGUS,  DUHRING'S  DISEASE  OR 
POLYMORPHOUS  DERMATITIS  (BROCQ). 

A  well-characterized  dermatosis  in  typical  cases  was  described 
by  Duhring,  in  1884,  under  the  name  of  dermatitis  herpetiformis. 

This  affection,  which  the  Vienna  School  confused  with  chronic 
pemphigus  and  multiform  erythema,  was  designated  by  the  old 
French  writers  as  pemphigus  with  small  bulla?,  or  pruriginous 
pemphigus,  or  "arthritide  bulleuse"  (Bazin).  English  authors, 
following  Tilbury  Fox  and  Colcott  Fox,  prefer  the  name  of  hydroa 
herpetiforme. 


180 


BULLM  AND  BULLOUS   DERMATOSES 


In  the  opinion  of  Brocq,  who  thoroughly  investigated  this  ques- 
tion the  disease  is  entirely  distinct  from  pemphigus;  and  since  the 
eruption  is  far  from  being  invariably  herpetiform,  he  extended  the 
scope  proposed  by  Duhring  and  established  a  group  of  painful  poly- 
morphous dermatitides  [dermatites  polymorphes  douloureuses]  com- 
prising  numerous  forms  or  varieties.  This  view  is  becoming  more 
and  more  generally  adopted. 

Personally,  like  many  others,  I  put  together  under  the  name  ot 
Duhring's  disease  all  the  varieties  of  the  disease,  of  which  the 
American  author  originally  described  only  the  form  with  small 
vesiculaT  lesions.  Instead  of  attempting  to  multiply  the  clinical 
types,  according  to  the  dimensions  of  the  bullae,  etc.,  I  shall  endeavor 
to  map  out  a  general  view,  in  the  following  description: 


1  ig.  55.     1  termatitis 


of  Duhring.    Anterior  aspect  of  arm  and  right  axilla. 


Symptoms.     E 
disease:      1    Tfc 


,,■  clinical  features  arc  characteristic  of  Duhring's 
polymorphism  of  the  eruption;    2    painful  phe- 
nomena, usually  very  pronounced:    (3    the  usual  preservation  of 

]  general  health;     1    the  tendency  to  recurrences.     [The  tetrad 

of  symptoms  which  seem  most  characteristic  are:  The  polymor- 
phic.i  of  the  lesions;  their  more  or  less  marked  herpetic  grouping; 
the  pruritus  and  the  tendency  to  recurrences.     Sensations  of  pain 


RECURRENT  PEMPHIGUS  OR  DUE RING' S  DISEASE      181 

are  noted  in  the  minority  of  the  cases  in  my  experience.]  The  onset 
is  marked  sometimes  by  the  eruption,  sometimes  by  a  preliminary 
pruritus. 

1.  The  eruption  is  polymorphous  and  presents  itself  under  very 
variegated  aspects  (Fig.  55);  it  often  covers  a  large  portion  of  the 
limbs  and  the  body.  It  is  composed  of  erythematous  patches, 
papules,  vesicles,  bulla?  and  sometimes  pustules. 

The  multiple  spots  or  erythematous  patches  are  often  urticarial 
and  marginated ;  in  the  same  case,  they  may  have  nummular  dimen- 
sions or  resemble  large  polycyclic  surfaces;  more  rarely,  simple 
papules  are  met  with. 

A  tendency  to  bleb-formation  manifests  itself  early  through  the 
appearance,  on  the  surface  of  the  patches,  of  sometimes  uniform, 
herpetiform,  grouped  or  scattered  vesicles,  often  arranged  as  a 
border;  or  bulla?  may  be  seen,  from  the  size  of  a  pea  to  that  of  a  nut, 
with  clear  or  rapidly  purulent  contents.  Vesicles  or  bullae  may  also 
originate  in  the  healthy  skin  in  the  vicinity  of  the  patches,  or  they 
may  swarm  out  to  a  distance.  In  a  general  way,  the  figured  erythe- 
matous patches,  interspersed  with  herpetiform  vesicles  or  bulla?  are 
the  most  characteristic  feature. 

The  most  frequent  initial  localization  is  on  the  limbs,  especially 
on  the  forearms;  but  the  eruptioa  may  start  anywhere.  It  proceeds 
by  enlargement  of  the  primary  lesions  and  the  production  of  new 
lesions,  appearing  every  two  or  three  days  in  small  numbers,  or  in 
large  crops  every  five  to  ten  days.  The  duration  of  each  lesion  is 
limited,  however.  The  erythema  fades;  the  vesicles  and  bulla? 
burst  through  scratching  and  are  replaced  by  red  surfaces,  raw  or 
covered  with  crusts;  the  latter  fall  off  and  leave  pigmentary  macules, 
very  rarely  cicatrices.  Lesions  of  different  age  are  thus  present  at 
the  same  time. 

As  a  rule,  the  eruption  is  decidedly  symmetrical.  It  affects  espe- 
cially the  limbs,  the  buttocks,  the  chest,  etc.,  but  has  a  tendency  to 
cover  the  entire  body;  possibly  the  face,  the  scalp,  the  palms  of  the 
hands  and  the  soles  of  the  feet  are  less  frequently  involved.  When 
the  last-named  regions  become  keratotic,  arsenic  medication  may 
possibly  be  responsible. 

The  mucous  membranes,  more  particularly  the  buccal  mucosa,  are 
affected  in  nearly  one-half  of  the  cases;  the  lesions  here  resemble 
those  of  hydroa.  [Involvement  of  the  mucosa  is  by  no  means  so 
frequent  in  this  country  as  in  the  author's  experience.] 

An  endless  number  of  eruptive  varieties  might  be  described;  but 
it  is  enough  to  point  out  that  the  predominant  lesion  may  take  the 
form  of  erythema,  or  of  herpetiform  vesicles,  these  being  the  cases 
which  Duhring  had  in  mind,  or  of  bulla?,  which  led  Kaposi  and  his 
school  to  see  in  this  affection  merely  a  modified  form  of  pemphigus 


182  BULLM  AND  BULLOUS  DERMATOSES 

vulgaris.  American  and  English  writers  have  described  a  pustular 
variety,  with  pustules  from  the  onset.  Sometimes  the  bullae  are 
extensive  and  plainly  vegetative  in  character. 

Cases  are  observed  in  which  the  eruption  is  localized  in  a  certain 
region  of  the  body;  other  cases  in  which  polymorphism  is  absent, 
notably  in  children  or  youthful  individuals,  vesicles  or  bullae  occur- 
ring exclusively.  In  still  other  cases,  on  the  contrary,  nothing  is 
seen  but  patches  of  marginate  erythema,  incessantly  recurrent  and 
pruritic,  with  very  scanty  vesiculation. 

2.  The  painful  phenomena  are  one  of  the  fundamental  charac- 
teristics of  Duhring's  disease,  but  cannot  be  considered  as  constant 
and  pathognomonic,  as  claimed  by  Besnier  and  Brocq.  They  con- 
sist of  sensations  of  itching,  heat,  burning  or  acute  pain.  They  may 
precede  the  eruption  by  a  few  days,  but  are  especially  liable  to 
accompany  each  crop,  with  exacerbations  in  the  evening  and  during 
the  night.  Although  usually  of  moderate  severity,  the  patient's 
sufferings  may  reach  an  intolerable  degree,  and  have  even  led  to 
suicide. 

3.  The  general  condition,  notwithstanding  the  very  extensive 
cutaneous  lesions,  the  pruritus  and  the  insomnia  remains  remarkably 
good,  the  patients  eating  and  digesting  well  and  losing  no  flesh. 
In  exceptional  cases  attacks  of  diarrhea  or  a  slight  rise  of  tempera- 
ture have  been  noted.  The  visceral  complications  (pulmonary  and 
especially  renal)  which  have  been  said  to  occur,  are  probably 
referable  to  intercurrent  diseases. 

4.  The  course  is  variable.  Attacks  as  described  above  last  from 
six  weeks  to  three  months,  sometimes  six  months  or  a  year.  But 
they  are  often  followed  by  a  subsidence,  or  even  a  return  to  normal, 
lasting  several  weeks,  several  months  or  even  a  year  or  longer, 
then  a  new  attack  supervenes,  and  so  on  at  irregular  intervals,  up 
to  ten  or  fifteen  times.  Finally,  the  attacks  become  milder  and 
ultimately  cease.  The  proportion  of  recoveries  can  hardly  be 
specified. 

The  disease  is  sometimes  prolonged  until  death,  which  in  rare 
cases  is  due  to  pemphigus  foliaceus  or  to  cachexia:  much  more  fre- 
quently to  an  intercurrent  affection.  Hence,  although  Duhring's 
disease  must  tie  considered  as  very  grave,  this  is  rather  on  account  of 
its  long  duration,  the  suffering  caused  by  it  and  the  interference  with 
social  relations  which  it  entails  than  on  account  of  a  risk  to  life. 

Its  practically  constant  tendency  to  proceed  not  only  in  small 
distinct  or  continuous  crops,  but  in  attacks  or  recurrences  separated 
by  periods  of  subsidence,  seems  to  me  to  constitute  one  of  its  most 
characteristic  features. 

Cases  with  identical  symptoms  are  observed,  however,  in  which 
the  disease  is  restricted  to  a  single  attack,  mild  or  severe.    These 


RECURRENT  PEMPHIGUS  OR  DUH RING'S  DISEASE      183 

may  be  classified  under  polymorphous  erythema.  Brocq  admits  a 
group  of  acute  non-recurrent  painful  polymorphous  dermatitis. 

Pathological  Anatomy. — The  erythematous  plaques  are  composed 
of  congestion,  with  well-marked  edema  and  abundant  diapedesis 
in  the  papillary  body;  eosinophile  cells  are  present  in  large  numbers. 

The  bullse  form  as  the  result  of  subepidermic  rupture  (Fig.  56), 
sometimes  subcorneal  rupture.  Occasionally  they  result  from 
enlargement  of  interstitial  vesicles.  Deep  or  superficial  bleb- 
formation  is  accordingly  observed  in  this  disease  together  with 
vesiculation. 

The  fluid  of  the  vesicles  or  bulla?  contains  at  first  a  large  pre- 
ponderance of  eosinophiles,  in  a  proportion  of  30  to  95  per  cent. 
The  blood  usually  shows  from  12  to  15  eosinophiles  in  100  white 
corpuscles,  sometimes  only  5  per  cent.,  exceptionally  up  to  30  per 
cent.    There  are  no  constant  visceral  or  nervous  lesions. 


Fig.  -56. — Histology  of  Duhring's  disease.  Section  of  one  of  the  bullae  represented 
in  Fig.  55.  Note  that  the  bulla  is  subepidermic;  the  epidermis  has  been  raised  as  a 
whole  by  the  fluid  exudate.  Among  the  white  corpuscles  seen  at  the  floor  of  the 
cavity  or  scattered  in  the  cutis  are  many  eosinophile  cells.      X  50. 

Etiology  and  Character. — Although  a  rare  affection,  Duhring's 
disease  is  nevertheless  the  most  common  bullous  disease  of  the 
pemphigus  group.  It  seems  to  be  more  widely  distributed  in  England 
and  in  America.  It  is  observed  in  very  young  children,  in  youthful, 
middle-aged  or  old  individuals,  in  both  sexes  alike.  [In  American 
dermatological  practice  it  is  seen  in  the  ratio  of  one  case  out  of  five 
hundred.] 

The  etiology  is  unknown  and  the  cause  has  been  sought  in  a  neuro- 
pathic constitution,  overwork,  emotional  disturbances,  alimentary 
or  medicinal  intoxications.  The  disease  is  not  at  all  contagious 
nor  can  it  be  inoculated.  Two  principal  theories  are  held  by  the 
majority  of  writers:     Some  believe  that  endogenous  or  exogenous 


1S4  BULLM  AND  BULLOUS   DERMATOSES 

toxins  of  microbic  or  other  origin  act  upon  the  nervous  system, 
causing  the  pruritus  and  the  eruption.  In  the  opinion  of  others  the 
eosinophils,  which  in  this  disease  exists  in  the  blood  as  well  as  in 
the  cutaneous  lesions  (as  shown  by  the  investigations  of  Leredde 
and  Ch.Perrin),  indicates  its  hematogenous  origin  (hematoderma), 
the  bone-marrow  being  probably  primarily  affected. 

Eosinophilia,  the  significance  of  which  is,  moreover,  imperfectly 
understood,  may,  however,  be  absent  in  Duhring's  disease,  whereas, 
on  the  contrary,  it  sometimes  [commonly]  exists  in  other  bullous 
affections,  pemphigus  foliaceus,  pemphigus  vegetans  and  even 
exceptionally  in  chronic  pemphigus,  as  I  have  been  able  to  demon- 
strate. 

Treatment. — All  lotions  and  applications  in  common  use  for  itching 
affections  June  been  tried,  with  variable  results.  Some  cases  may 
derive  benefit  from  the  employment  of  absorbent  powders,  or  moist 
dressings,  which,  however,  tend  to  mac-crate  the  epidermis;  or 
from  the  application  of  Hme-and-oil  liniment  or  various  creams; 
while  others  do  well  under  simple  pastes,  or  even  sulphur  or  tar 
pastes.  Large  bulla?  should  be  pierced  with  a  flamed  needle;  the 
excoriations  are  dressed  with  naphtalan,  cold  cream  or  lanolin.  In 
ease  of  very  extensive  lesions  where  the  dressing  exhausts  the  patient 
too  much,  he  may  be  placed  between  two  sheets  in  a  thick  layer  of 
talcum  powder  (dry  treatment). 

(lateral  Treatment-  'Die  most  popular  internal  treatment  is 
arsenic,  in  progressive  long-continued  doses,  administered  in  hypo- 
dermic injections,  if  necessary.  Novarsenobenzol  has  been  found  to 
be  very  efficacious  in  certain  cases.  Balzer  advocates  adrenalin. 
I  have  sometimes  obtained  remarkable  but  very  unreliable  results 
from  repeated  injections  of  physiological  salt  solution  or  isotonic 
sea-water,  or  sugar  solutions,  hypertonic  or  not.  It  must  be  kept  in 
mind  that  hypodermic  injections  in  large  doses,  and  still  more  so 
intravenous  injections,  with  or  without  preliminary  bloodletting, 
may  give  rise  to  a  well-marked  febrile  reaction.  It  is  desirable  to 
further  investigate  this  mode  of  medication,  as  well  as  serotherapy 
with  organic  sera  in  its  different  forms  (autoserotherapy,  etc.).  [On 
the  subject  of  autoserotherapy  the  views  of  American  authors  are 
greatly  divergent;  a  few  speak  enthusiastically  of  its  value,  others 
find  it  of  no  use.] 

In  all  cases  a  very  strict  diet  must  be  prescribed,  free  from 
stimulants,  preferably  a  milk  diet,  and  all  organic  functions  must  be 
carefully  supervised. 

Rare  Dermatoses  Related  to  Duhring's  Disease. — Under  this 
heading  I  have  grouped  a  number  of  pathological  forms  which  have 
received  special  names,  but  are  perhaps  merely  varieties  of  the  dis- 
ease described   above.     This  remark   is  certainly  true  of  herpes 


RECURRENT  PEMPHIGUS  OR  DUH RING'S  DISEASE      185 

gestationis  of  Milton  and  Duncan  Bulkier.  This  condition  is  really 
a  Duhring's  disease,  with  the  special  characteristic  of  developing  in 
the  course  of  pregnancy,  in  the  fifth  to  sixth  month,  or  sometimes 
after  delivery.  The  attack  lasts  a  few  weeks  to  several  months. 
Recurrence  is  the  rule  with  each  succeeding  pregnancy,  each  attack 
occurring  earlier  in  the  course  of  the  gestation  and  lasting  longer. 

Hydroa  puerporum  of  Unna  is  in  all  probability  likewise  a  form 
of  Duhring's  disease,  appearing  in  young  children  in  the  form  of 
acute  polymorphous  attacks,  recurring  especially  in  the  summer 
and  disappearing  around  the  age  of  puberty. 

Hydroa  Vacciniforme  of  Bazin,  or  Summer  eruption  of  Hutchinson, 
seems  to  be  an  altogether  different  kind  of  affection.  The  eruption, 
sometimes  preceded  by  general  malaise,  accompanied  by  a  burning- 
sensation  and  local  tension,  is  not  polymorphous,  but  vesiculo- 
bullous.  At  first  tense  and  prominent,  the  small  lenticular  bulla? 
spread  out,  become  umbilicated,  attain  the  size  of  a  finger-nail, 
become  transformed  into  brownish  pustules  with  a  central  depres- 
sion and  dry  in  crusts  which  leave  cicatrices  resembling  the  pits  of 
smallpox.     Central  necrosis  is  occasionally  noted. 

The  eruption  occupies  the  exposed  regions,  especially  the  cheeks, 
the  nose,  the  ears  and  the  hands,  being  very  rarely  found  elsewhere. 
It  appears  in  the  spring,  under  the  influence  of  exposure  to  light, 
notably  short-wave  rays,  as  has  been  demonstrated  experimentally. 
The  patients,  as  a  rule,  have  hematoporphyrinuria.  The  affection 
begins  in  the  first  few  years  of  life,  and  usually  ceases  spontaneously 
at  the  age  of  twenty  to  thirty  years. 

There  is  accordingly  a  hypersusceptibility  to  light  radiations,  due 
to  abnormal  tissue-juices;  it  is  an  established  fact  that  hemato- 
porphyrin  sensitizes  toward  the  action  of  light. 

As  to  the  relations  of  Impetigo  herpetiformis  of  Hebra-Kaposi, 
studied  in  France  by  Dubreuilh,  with  herpes  gestationis  and  Duhr- 
ing's disease  great  uncertainty  prevails.  This  very  rare  affection  is 
practically  restricted  to  pregnant  women,  although  a  few  cases  are 
said  to  have  been  observed  in  men. 

The  eruption  consists  of  red  and  swollen  nummular  spots  which 
became  covered  with  small  miliary  pustules,  increase  in  size  and 
became  confluent  in  large  surfaces,  crusted  in  the  center  and  pus- 
tular at  the  periphery.  It  usually  starts  in  the  inguino-crural  region, 
the  umbilicus,  the  loins  or  axilla?,  and  may  become  generalized,  even 
involving  the  mucosa?.  Severe  general  symptoms  are  present,  in 
the  form  of  chills,  remittent  fever,  a  typhoid  condition,  tetany, 
eclampsia.  In  19  of  84  cases  collected  by  Borzecki,  the  outcome 
was  death. 

No  cultures  can  be  grown  on  ordinary  media  from  the  contents  of 
the  pustules.     If  the  condition  is  not  a  septicemia,  but  another 


186  BULLJE  AND  BULLOUS  DERMATOSES 

pregnancy  auto-intoxication,  as  in  herpes  gestationis,  it  would  be 
reasonable  to  try  injections  of  serum  from  normal  pregnant  women. 

It  is  also  not  known  at  the  present  writing  if  the  continuous  acro- 
dermatitis of  Hallopeau  and  others,  or  recurrent  phlyctenoses  of  the 
extremities  of  Andry,  are  pyodermatitides  favored  by  a  predisposed 
trophoneurotic  territory,  or  clinical  forms  of  1  hihring's  disease.  The 
affection  begins,  at  any  age,  under  the  guise  of  a  whitlow;  but  new 
purulent  bullne  form  incessantly,  invading  the  entire  finger,  then 
other  fingers  and  the  hand,  in  islands  or  over  a  continuous  surface. 
The  other  extremities  are  attacked  in  their  turn.  Radiating  pains 
and  pruritus  are  present.  The  affection  lasts  for  years,  with 
paroxysms,  but  without  healing  nor  extending  over  the  body.  The 
nails  finally  fall  out  (compare  impetiginous  onyxis);  the  skin 
becomes  atrophic  and  remains  red. 

Aside  from  this  suppurative  form  of  acrodermatitis,  a  vesicular 
form  has  been  described,  characterized  by  isolated  vesicles,  on  a  red 
base,  incessantly  reproduced  on  the  same  fingers  and  related  to  the 
zosteriform  eruptions. 


CHRONIC  PEMPHIGUS. 

This  name,  or  that  of  genuine  pemphigus  (pemphigus  vulgaris), 
is  reserved  by  me,  with  Besnier  and  Brocq,  for  a  rare  and  almost 
invariably  fatal  progressive  bullous  disease,  the  most  dangerous 
among  the  great  malignant  skin  diseases. 

Symptoms. — Genuine  pemphigus  usually  begins  about  the  mouth, 
the  pharynx  or  lips,  the  nasal  fossae  [the  conjunctivae],  or  some- 
times on  the  anterior  aspect  of  the  chest. 

The  eruptive  lesion  on  the  skin  consists  of  round  rather  large- 
sized  bullae,  of  nummular  dimensions,  tense  or  flaccid,  with  yellowish 
or  turbid  contents.  They  develop  very  rapidly  on  the  healthy  skin ; 
their  base  becomes  reddened  at  the  end  of  a  few  hours,  or  when  they 
suppurate.  Whether  ruptured  or  not,  they  may  undergo  two  different 
evolutions,  either  drying  in  crusts  which  are  shed  at  the  end  of  eight 
or  ten  days  and  leave  a  red  or  brownish  macule;  or  the  roof  of  the 
bulla  becomes  detached,  exposing  a,  smooth  bright  red  surface  which 
sometimes  suppurates.  They  do  not  enlarge  much,  but  multiply  in 
incessant  new  crops. 

In  advanced  stages  of  the  disease  the  erosions  are  slow  to  become 
covered  with  epidermis;  they  run  together  here  and  there  in  poly- 
cyclic,  raw  or  crusted  lesions,  surrounded  by  bullous  elevations 
(Fig.  57)  and  may  cover  a  considerable  portion  of  the  integument, 
more  or  less  simulating  eczema  or  an  exfoliative  dermatitis. 

According  to  the  contents  and  the  behavior  of  the  bullae,  the 


CHRONIC  PEMPHIGUS 


187 


terms  hemorrhagic,  ulcerative,  diphtheroid,   gangrenous  pemphigus, 
etc.,  have  been  employed. 

The  eruption  occupies  especially  the  folds,  the  neck,  the  axillae, 
the  anogenital  and  inguinocrural  regions,  the  umbilicus,  the  periph- 
ery of  the  nails,  as  well  as  points  subjected  to  pressure,  such  as  the 
buttocks,  trochanters,  scapulae,  knees,  heels,  ears;  but  there  is  a 
tendency  to  almost  complete  generalization. 


Fig.  57. — Genuine  chronic  pemphigus  in  an  exhausted  old  man.    The  eruption  dates 
a  month  back,  the  patient  died  less  than  seven  weeks  from  the  time  of  its  onset. 


In  the  mouth  the  lesions  are  primary  or  precocious,  very  transi- 
torily bullous,  assuming  the  appearance  of  a  diphtheroid  angina  or 
ulcerative  membranous  stomatitis,  and  promptly  spreading  to  the 
lips.  The  nasal,  conjunctival,  vulvar  and  other  mucous  membranes 
are  very  often  affected  in  a  similar  way. 


188  BULLAE  AND  BULLOUS  DERMATOSES 

At  ;i  certain  stage  of  the  disease  Nikolsky's  sign  is  invariably 
present;  by  forcible  pressure  exerted  on  the  patient's  skin  with  the 
pulp  of  the  finger,  the  horny  layers  can  be  detached  and  made  to 
slip  off;  moreover,  a  moderate  amount  of  pressure  gives  rise  to  the 
appearance  of  a  bulla.  This  sign,  which  indicates  acantholysis,  is 
also  met  with  in  pemphigus  foliaceus,  in  congenital  pemphigus,  and 
in  the  grave  form  of  Duhring's  disease. 

Pruritus,  formication  and  heat  sensations  may  he  entirely 
absent,  the  bullae  developing  without  the  patient's  knowledge  when 
this  is  the  case,  in  contradistinction  to  Duhring's  disease.  But  the 
excoriations,  sores  and  buccal  lesions  cause  severe  pain.  Adhesions 
may  develop  between  two  mucous  surfaces;  serious  changes  of  the 
conjunctivae  and  cornea-  may  occur;  the  nails  and  hairs  fall  out. 


- 

Fig.  58. — Histology  of  genuine  chronic  pemphigus.  Flaccid  subcorneal  bulla,  very 
recently  developed,  derived  from  the  case  shown  in  I"i<r.  57.  The  cavity  contains 
a  sero-albuminous  fluid  in  which  float  numerous  white  corpuscles  arid  a  few 
epithelial  cells.  The  adhesion  of  the  epidermal  cells  with  each  other  is  diminished: 
on  the  borders  of  the  blebs,  the  corneal  layer  tends  to  become  detached  from  the  rete; 
Nikolsky's  sign  was  present  to  a  marked  degree  in  this  case.      X  65. 

The  general  phenomena  consist  of  nervous  depression  or  excite- 
ment, anorexia,  extremely  rapid  emaciation ;  finally  diarrhea, 
vomiting,  cachexia  and  sometimes  a  transformation  into  pemphigus 
foliaceus,  lead  to  death.  Fever  has  been  noted,  being  sometimes 
accounted  for  by  the  existence  of  abscesses,  ulcers,  or  sloughs. 

The  course  is  rapidly  progressive.  The  fatal  termination  takes 
place  in  three  to  eighteen  months,  rather  less  than  more,  through 
cachexia  or  an  intercurrent  infection. 

Cases  have  been  reported,  and  have  come  under  my  personal 
observation,  possessing  all  the  characteristics  of  true  pemphigus, 
instead  of  Duhring's  disease,  which  nevertheless  terminated  in 
recovery  or  in  a  complete  remission  lasting  several  years.  We  are 
obliged  therefore  to  admit  the  existence  of  a  benign  form. 

Diagnosis.  This  is  usually  very  precarious  at  the  onset,  and  it 
has  well  been  said  that  there  exist  no  two  exactly  similar  cases  of 


PEMPHIGUS  FOLIACEUS  189 

genuine  pemphigus.  The  most  experienced  dermatologists  some- 
times hesitate  in  the  presence  of  the  early  lesions  which  have  the 
appearance  of  stomatitis,  angina,  toxidermia,  hydroa,  or  Duhring's 
disease.  In  the  developed  stage,  the  clinical  picture  becomes  clear 
and  more  or  less  approximates  the  description  given  above. 

Pathological  Anatomy. — The  bulla?  are  so  fragile  that  it  is  difficult 
to  obtain  unruptured  specimens  for  examination.  The  cavity  may 
be  subcorneal,  intramalpighian,  or  subepidermic.  Underneath  the 
bulla,  the  derma  is  edematous,  but  contains  only  a  few  wandering 
cells. 

The  subjoined  figure  (Fig.  58)  gives  an  idea  of  these  lesions. 

Eosinophils  are  not  usually  found  either  in  the  fluid  contents  of 
the  bullse  or  in  the  neighboring  tissues.  The  contents  are  sterile  or 
enclose  microbes  of  secondary  infections.  Blood  cultures  are  usually 
negative.  The  investigations  of  Lipschutz  point  to  protozoa  as 
the  responsible  agents.  [?] 

Etiology  and  Character. — Chronic  pemphigus  attacks  especially 
weakened  exhausted  individuals  past  the  age  of  forty  years,  some- 
what more  frequently  males.  The  Jewish  race  seems  to  be  pre- 
disposed to  it. 

The  disease  is  not  contagious,  and  there  is  nothing  to  prove  its 
infectious  character.  It  may  equally  well  be  claimed  to  result  from 
a  severe  affection  of  the  central  nervous  system,  or  possibly  from 
an  auto-intoxication. 

Treatment. — The  external  treatment  is  that  of  the  other  bullous 
skin  affections.  Internal  medication  has  for  a  long  time  been  con- 
sidered absolutely  ineffective,  so  that  the  patient's  strength  was 
simply  kept  up  by  means  of  nourishing  food,  fresh  air,  tonic  medic- 
inal agents,  strychnin,  etc.  Recently,  various  authors  have  re- 
ported improvement  and  even  cures,  by  means  of  quinin  (1.0  to  2.5 
gm.  daily),  antipyrin,  arsenic,  and  especially  arsenobenzol,  as  well 
as  by  injections  of  normal  serum.  These  therapeutic  measures 
should  accordingly  be  resorted  to,  instead  of  considering  the  situ- 
ation as  hopeless. 

PEMPHIGUS  FOLIACEUS. 

This  term  is  applied,  since  Cazenave,  to  a  skin  disease  which 
begins  with  pemphigus  and  becomes  transformed  into  an  exfoliative 
erythroderma.  It  is  difficult  to  give  a  clear  description  of  its 
extremely  variable  clinical  picture  and  course.  The  onset  may  be 
that  of  chronic  pemphigus,  or  more  rarely  Duhring's  disease;  or 
there  may  be  a  bullous  dermatosis  impossible  of  classification, 
with  rare  and  discrete,  then  numerous  and  close-set  bulla?,  often 
remarkably  flaccid.  Depending  on  its  course,  pemphigus  foliaceus- 
is  called  secondary  or  primary, 


100 


BULL.E  AND  BULLOUS  DERMATOSES 


In  the  transition-stage,  no  more  normal  epidermis  is  formed  at 
the  points  occupied  by  the  bullae,  but  instead  lamellar,  leaf-like, 
moist  scales  or  crusts,  which  cover  large  red  surfaces,  sometimes 
extending  over  almost  the  entire  body  (Fig.  59).  This  epidermis 
is  incapable  of  forming  the  roof  of  blisters  and  these  are  replaced  by 
oozing  spits  from  which  the  scales  arc  easily  detached.  Under  the 
scales  or  at  the  macerated  points,  a  highly  offensive  epidermic  mass 


foliaceus  of  four  ye 
twenty-five  years. 


:i   woman 


a  god 


is  found,  made  up  of  isolated  Malpighiaii  cells.  On  the  borders  of 
the  squamous  surfaces  is  seen  a  bullous  margin,  especially  in  the 
vicinity  of  the  hands  and  feet  which  sometimes  escape. 

Finally,  the  lamellar  exfoliation  becomes  general  and  resembles 
that  of  the  other  erythroderniias;  it  is  sometimes  so  abundant  that 
handfuls  of  epidermal  structures  can  be  picked  up  from  the  patient's 
bed.     However,   it  usually   retains  a   peculiar  moisture. 


CONGENITAL  PEMPHIGUS  191 

The  skin  is  a  dark  or  brownish  red,  thinned  and  tense,  or  not 
infrequently  papillomatous;  fissures  appear  in  the  articular  folds 
and  ectropion  develops  on  the  eyelids.  The  hairs  of  the  scalp  and 
body  become  scanty;  the  nails  become  streaked  and  hooked  and  may 
fall  out.    The  mucous  membranes  usually  remain  intact. 

Pemphigus  foliaceus  is  the  disease  in  which  Nikolsky  described 
the  sign  of  easy  detachability  of  the  horny  layer,  which  he  believed 
to  be  pathognomonic. 

Pruritus  and  heat  sensation  are  not  prominent,  except  period- 
ically. The  urine  is  scanty  and  the  urea  and  nitrogen  index  is 
always  low. 

The  disease  is  protracted,  sometimes  lasting  five  to  ten  years, 
often  only  two  or  three  years.  It  regularly  terminates  in  death, 
due  to  digestive  disturbances,  especially  diarrhea,  marasmus,  or 
intercurrent  complications. 

The  pathological  anatomy  has  yielded  divergent  findings.  The 
epidermis  was  found  to  be  tense  and  thinned  or  there  were  greatly 
elongated  papillse  and  intrapapillary  buds,  with  dermic  and  epidermic 
edema  and  abundant  exocytosis.  The  condition  of  the  granular 
layer  is  variable.  Eosinophilia  is  noted  in  the  blood.  Various 
lesions  of  the  nerve  centers  have  been  described,  but  are  inconstant. 

Pemphigus  foliaceus  is  encountered  in  both  sexes,  among  adults 
in  a  state  of  physical  or  psychic  deterioration. 

We  do  not  know  if  it  is  of  nervous,  toxemic,  hematodermic,  or 
other  origin.  It  seems  that  certain  cases  can  be  interpreted  as 
malignant  exfoliative  herpetides,  secondary  to  a  pemphigus;  the 
appearance  of  other  cases  is  that  of  a  distinct  pathological  entity. 

The  treatment  must  follow  that  of  the  other  bullous  skin  diseases 
and  the  erythrodermas. 

CONGENITAL  PEMPHIGUS. 

This  is  a  cutaneous  malformation  rather  than  a  disease ;  it  is  very 
rare,  usually  familial  or  hereditary,  as  a  rule  congenital,  but  occasion- 
ally does  not  mainfest  itself  until  late  childhood,  or  still  later.  From 
various  sources  attention  has  been  called  to  the  apparent  influence 
of  consanguinity  of  the  parents. 

It  consists  of  a  predisposition  of  the  skin  and  sometimes  of  the 
mucous  membranes,  to  react  in  the  form  of  bullse  toward  all  trau- 
matisms, pressures,  or  even  slight  bruises. 

Two  degrees  are  known,  and  by  some  are  considered  as  separate 
types  of  the  disease:  The  first,  epidermolysis  hereditaria  bullosa 
of  Kobner,  or  simple  traumatic  hereditary  pemphigus,  consists 
merely  of  a  tendency  to  the  formation  of  tense,  subcorneal,  serous 
or  sero-sangumolent  blisters;  these  develop  in  the  healthy  skin, 


192  HI  1.1..K  AND  BULLOUS  DERMATOSES 

under  the  influence  of  blows,  or  pressure  by  the  clothing,  shoes, 
etc.  The  feet,  hands,  wrists,  elbows,  knees,  etc.,  and  even  the 
buccal  mucosa  arc  affected  with  blebs,  which  come  on  without  pain 
in  less  than  an  hour  after  the  traumatism  and  which  heal  very 
readily,  provided   infection  does  not  occur. 

In  the  second,  the  grave  and  dystrophic  form — "Pemphigus 
successif  a  Kystes  epidermiqujes"  or  congenital  pemphigus  with  a 
tendency  to  cicatrization — an  apparently  spontaneous  production 
of  more  or  less  numerous  bullae  is  noted  at  various  points  of  the 
limbs  and  body,  within  a  short  time  after  birth.  There  is  a  constant 
succession  of  these  bullae,  especially  in  regions  exposed  to  pressure, 
on  the  extremities,  the  ears,  the  knees  and  elbows,  even  on  the 
mucous  membranes. 

Gradually  the  skin  of  certain  regions,  principally  that  on  the 
back  of  the  hands  and  the  joints  of  the  fingers,  the  elbows  and  knees, 
etc.,  becomes  atrophic  or  cicatricial,  thin  like  onion  peel,  of  a 
brownish  purplish-red  color.  An  enormous  number  of  very  small 
white  opaque  granules  are  seen;  these  are  milium  cysts.  The  nails 
undergo  various  deformities,  or  fall  out  permanently. 

The  microscope  discloses  atrophy  of  the  derma  with  disappear- 
ance of  the  papillary  body  and  shows  that  the  cysts  are  dilatations 
of  the  sweat  ducts  with  corneal  contents  or  more  rarely  follicular 
cysts.  Similar  miliary  cysts  and  atrophic  changes  are  noted  in  some 
cases  of  1  hihring's  diseases. 

In  the  congenital  forms  of  pemphigus,  Xikolsky's  sign  of  easy 
detachability  of  the  horny  layer  is  almost  invariable  present.  In 
certain  cases,  a  combination  has  been  demonstrated  between 
congenital  pemphigus  and  various  forms  of  congenital  ichthyosiform 
hyperkeratosis.  On  the  other  hand,  Nicolas,  Montot  and  Charlet 
have  described  a  type  with  chronic  and  progressive  vegetative 
ulcerations. 

'Phe  pathological  predisposition  usually  diminishes  with  the 
advance  of  years;  or  it  may  become  limited  to  some  particular 
region. 

The  patient  must  be  cautioned  against  all  exposure  to  traumatism. 
Protective  dressings  and  tonic  internal  medication  are  indicated. 

PEMPHIGUS  HYSTERICUS. 

Hysterical  pemphigus  does  not  exist,  as  has  been  shown  by 
investigations  and  conclusive  discussions. 

1  fnder  tins  name,  or  under  that  of  drginal  or  chlorotic  pemphigus, 
were  designated  attacks  of  bullous  eruptions,  hemorrhagic,  pustular 
or  sloughing,  which  occurred  in  nervous  girls  or  young  women  of 
peculiar  character. 


PEMPHIGUS  HYSTERICUS  193 

The  lesions,  often  of  an  irregular  or  elongated  shape,  are^dis- 
tributed  in  a  remarkable  fashion,  sometimes  with  suspicious  regular- 
ity. They  appear  one  by  one,  or  in  small  numbers  at  a  time, 
throughout  a  period  of  several  months  or  years.  The  course  is 
invariably  benign.  However,  through  their  extent,  numbers  and 
sometimes  gangrenous  character,  the  lesions  may  cause  actual 
mutilations. 

In  all  cases  which  could  be  seriously  investigated,  where  the 
patient  was  carefully  watched,  or  when,  for  example,  a  sealed 
occlusive  dressing  was  applied  over  the  affected  region,  the  condition 
could  always  be  traced  to  malingering.  The  lesions  are  burns  or 
cauterizations  by  chemical  or  medicinal  agents  and  are  produced  by 
the  patient  herself  under  the  influence  of  a  special  mental  state  which 
has  been  named  mythomania  or  pathomania.  These  are  cases  of 
dermatitis  artefacta.  The  truth  of  Babinski's  statement  is  beyond 
question,  that  hysteria  is  incapable  of  giving  rise  to  trophic  dis- 
turbances of  the  skin. 

The  exposure  of  trickery  demands  some  tact  on  the  part  of  the 
physician,  whose  suspicions  are  often  repudiated  by  the  patient's 
environment.  But  when  the  proof  of  the  fraud  has  once  been  made, 
the  so-called  eruption  subsides  of  its  own  accord. 


13 


CHAPTER  XI. 
KERATOSES. 

HYPERKERATOSES  AND  DYSKERATOSES. 

The  name  keratosis  is  applied  to  a  dermatological  lesion  which 
consists  in  moderate  thickening  of  the  horny  layer;  hyperkeratosis 
means  a  considerable  hyperplasia  of  this  layer;  dyskeratosis  is  a 
pathological  process  in  which  a  disturbed  keratinization  terminates 
in  the  formation  of  an  abnormally  constituted  corneal  layer,  with 
thickening  in  some  of  the  cases  and  disintegration  in  others. 

Under  normal  conditions,  the  horny  layer  is  formed  by  the  super- 
posed layers  of  lamellar  cells,  which  are  composed  of  keratin  and 
loaded  with  fat,  but  have  neither  protoplasm  nor  nuclei.  These 
corneal  cells  represent  the  ultimate  stage  of  the  process  of  epidermic 
development.  Originating  through  multiplication  of  the  constit- 
uents of  the  basal  layer,  the  Malpighian  cells  are  gradually  pushed 
up  by  the  newly  generated  cells  and  reach  the  granular  layer  where 
they  take  up  eleidin  or  keratohyalin,  after  which  they  suddenly 
undergo  the  transformation  known  as  keratinization. 

The  corneal  cells  adhere  to  each  other  and  persist  a  certain  time 
at  the  epidermal  surface,  where  they  constitute  a  resistant,  supple, 
and  only  slightly  permeable  protective  covering.  Being  no  longer 
alive,  the  horny  cells  are  incapable  of  vital  reaction  against  irritants 
of  any  kind  and  are  finally  shed. 

The  thickness  of  the  normal  horny  layer  varies  slightly  in  diffei- 
ent  individuals  and  greatly  in  different  regions  of  the  body. 

I  shall  begin  with  a  discussion  of  the  cutaneous  affections  char- 
acterized by  thickening  of  the  horny  layer,  leaving  to  the  end  of 
the  chapter  the  conditions  designated  dyskeratoses. 

KERATOSES  AND  HYPERKERATOSES. 

In  the  cutaneous  affections  characterized  by  a  thickening  of  the 
horny  layer  the  degree'  of  this  hyperplasia  is  variable — being 
slightly  marked  and  accompanied  by  a,  powdery  or  scurvy  desqua- 
mation in  kerosis  and  pityriasis  simplex  or  considerable,  often 
producing  a.  genuine  carapace,  resistant  and  liable  to  crack,  in  the 
iclitliyosiforni  hyperkeratoses  and  numerous  keratodermias;  in 
ichthyosis,  all  degrees  arc  met  with,  from  simple  xerodermia  to  the 
most  pronounced  sauriasis. 


KERATOSES  AND  HYPERKERATOSES  195 

In  a  general  way,  when  the  horny  layer  is  very  hyperplastic,  the 
granular  layer  and  the  mucous  body  are,  as  a  rule,  likewise  of  very 
abnormal  thickness;  the  derma  itself  is  usually  congested  and 
there  is  an  obvious  tendency  toward  the  production  of  papillary 
elevations  or  vegetations. 

The  name  of  verrucosa  state  is  applied  to  the  common  combination 
of  keratosis  with  the  vegetative  process  (XII). 

The  term  keratoma  is  sometimes  applied  to  a  circumscribed 
hypertrophy,  forming  a  tumor,  such  as  cutaneous  horns. 

From  the  point  of  view  of  the  distribution  of  the  lesions  on  the 
surface  of  the  integument,  a  distinction  must  be  made  between 
the  following  groups : 

1.  Diffuse  and  generalized  keratoses,  spreading  over  almost  the 
entire  body,  or  at  least  over  large  surfaces,  although  with  evident 
regional  predilections. 

In  this  group  I  shall  describe  kerosis,  pityriasis  simplex,  ichthyosis 
and  the  generalized  and  partial  ichthyosiform  hyperkeratoses. 

2.  Circumscribed  keratoses,  composed  of  distinctly  limited  kera- 
totic  spots  or  surfaces;  some  are  scattered  without  apparent  order, 
others  assume  a  regional  or  symmetrical  arrangement,  while  a  few 
are  even  distinctly  systematized. 

This  group  comprises:  keratotic  neii,  linear  nevi,  senile  warts, 
senile  keratosis  and  a  few  analogous  affections. 

It  is  not  superfluous  to  point  out  that  keratotic  lesions  in  scat- 
tered spots  or  on  more  or  less  extensive  surfaces,  may  be  present  or 
simulated,  in  a  large  number  of  skin  affections.  But  corns,  flat 
warts  and  common  warts  have  been  described  elsewhere.  The 
cutaneous  dystrophies  such  as  acanthosis  nigricans,  which  is  vege- 
tative and  xeroderma  pigmentosum,  in  which  the  lesions  of  the 
derma  are  important  and  essential,  likewise  belong  in  other  chapters. 

As  regards  the  patches  of  psoriasis  inveterata  and  ostreacea, 
lichen  hypertrophicus,  lupus  erythematodes  of  the  type  of  "herpes 
cretace,"  tuberculosis  verrucosa,  the  angiokeratomas,  etc. — the 
thickening  of  the  horny  layer  here  is  secondary  to  a  definite  process 
of  different  character.  They  are  here  mentioned  only  from  the 
viewpoint  of  the  differential  diagnosis. 

3.  Regional  keratoses  proper,  which  owe  very  peculiar  character- 
istics to  their  topographical  localization.  Such  are  notably  the 
palmar  and  plantar  keratoses,  for  which  I  reserve  the  name  of 
keratoderma. 

Although  the  epithelium  of  the  mucous  membranes,  more  par- 
ticularly that  of  the  mouth,  does  not,  under  normal  conditions, 
become  keratinized  like  the  epidermis,  local  pathological  lesions  are 
observed  which  are  properly  entitled  to  the  name  of  keratoses  of  the 
mucosce. 


196  KERATOSES 


KEROSIS. 


The  chronic  pathological  condition  of  the  skin  which  I  have 
named  kerosis,  is  characterized  clinically  by:  (1)  Dirty  yellowish 
or  grayish  coloration;  (2)  accentuation  of  the  pilo-sebaceous  pores; 
(3)  a  slight  thickening  of  the  integument. 

The  anatomical  lesions  are:  A  slight  diffuse  hypertrophy  of  the 
horny  layer,  with  a  tendency  to  fine  desquamation  and  a  modifi- 
cation, of  unknown  character,  of  its  fat  content;  hyperkeratosis 
of  the  pilo-sebaceons  orifices. 

This  dystrophy  finds  its  proper  place  in  the  group  of.  the  diffuse 
keratoses.  It  is  usually  misinterpreted  and  confused,  erroneously 
in  my  opinion,  with  seborrhea,  which  constitutes  merely  a  complica- 
tion. 

Although  of  slight  importance  in  itself,  kerosis  acquires  clinical 
interest  because  it  furnishes  the  necessary  or  ordinary  substratum 
for  several  of  the  most  common  cutaneous  affections.  Such  are 
certain  pityriases,  seborrhea,  certain  alopecias  and  hypertrichoses, 
hyperidrosis  oleosa,  some  acnes,  rosacea,  many  cczonatides. 

The  kerotic  pityriasis  will  be  described  in  the  following  paragraph. 
For  the  other  kerotic  affections,  the  reader  is  referred  to  the  chapters 
dealing  with  the  follicnloses,  trichoses,  hidroses  and  the  erythemato- 
squamous  dermatoses. 

The  topographical  distribution  of  kerosis  is  both  diffuse  and 
regional.  It  occupies  by  predilection  and  to  the  highest  degree,  the 
center  of  the  face,  especially  the  nose  and  the  nasogenial  furrows, 
and  the  seal]);  very  frequently  also  the  forehead,  the  temples,  the 
chin,  the  nape  of  the  neck;  on  the  trunk,  it  affects  especially  the 
pre-sternal  oval  and  the  interscapular  groove,  spreading  more  or  less 
around  the  middle  line.  It  often  covers  the  shoulders,  the  entire 
thorax,  uniting  at  the  sacrum  behind,  at  the  umbilicus  in  front;  it 
is  not  uncommon  on  the  pubis,  the  genital  organs,  the  intergluteal 
fold,  in  the  large  articular  folds  and  even  on  the  palms  of  the  hands. 

The  following  parts  invariably  escape:  the  front  of  the  neck,  the 
extensor  surface  of  the  limbs,  the  buttocks  and  the  forearms  and 
legs  as  a  whole. 

It  will  be  noted  that,  this  distribution  is  practically  the  opposite 
of  what  is  seen  in  ichthyosis. 

On  this  territory,  the  various  manifestations  and  complications 
of  kerosis  are  not  produced  haphazard,  but  each  has  its  preferred 
or  exclusive  regions. 

Numerous  factors  play  a  role  in  the  etiology  of  kerosis.  This 
anomaly  is  so  widely  distributed  in  civilized  countries  and  in  its 
mild  degrees  so  close  to  the  physiological  condition,  that  one  hesi- 
tates to  define  it  as  a  disease.     Certain  individuals,  more  or  less 


KEROSIS  197 

numerous  according  to  the  race,  are  immune.  Direct  heredity, 
or  the  influence  of  poor  health  or  bad  hygiene  of  the  parents, 
constitute  the  fundamental  conditions  of  kerosis.  The  establish- 
ment of  the  genital  functions  and  sexual  disturbances  on  the  one 
hand,  unhygienic  diet  on  the  other,  in  the  form  of  a  hypernitrog- 
enous  diet,  abuse  of  stimulants,  coarse  food,  insufficient  mastication, 
abnormal  fermentations,  constipation,  etc.,  are  common  factors, 
the  individual  effect  of  which  is  not  easily  determined. 

External  local  irritation,  reflex  circulatory  disturbances  con- 
nected with  affections  of  the  mucous  membranes,  play  a  much  less 
prominent  part. 

By  a  certain  school,  the  manifestations  of  kerosis  are  interpreted 
as  directly  microbic,  each  one,  according  to  Sabouraud,  being  refer- 
able to  a  special  variety  of  microbe  or  an  association  of  varieties. 
The  presence  of  microorganisms  is  indeed  undeniable,  but  their 
pathogenic  action  has  not  been  demonstrated. 

At  any  rate,  kerosis  and  its  manifestations  follow  a  certain  law  of 
evolution  in  connection  with  the  age  of  the  individual.  Dry  pity- 
riasis of  the  hairy  scalp,  appearing  at  the  age  of  six  to  ten  years, 
becomes  transformed  about  or  after  puberty  into  oily  pityriasis, 
seborrhea  developing  at  the  same  time.  Acne  juvenilis  flourishes 
from  the  age  of  fifteen  to  twenty-five  years.  Calvities  gravis 
begins  at  twenty-five  years,  or  less.  .  Rosacea  may  be  premature,  or 
be  delayed  until  about  the  age  of  forty-five  years.  In  aged  indi- 
viduals, the  sequelae  of  kerosis  become  attenuated  and  extinct,  unless 
it  be  held  accountable  for  seborrheal  warts  and  senile  keratosis. 

It  is  quite  possible  that  the  vernix  caseosa,  or  the  greasy  epidermic 
covering  of  some  infants  at  birth  and  the  so-called  acne  miliaris  of 
the  newborn  which  may  accompany  it,  represent  the  first  mani- 
festation of  kerosis.  This  would  be  an  additional  reason  for  regard- 
ing the  latter,  accepting  the  views  of  Jacquet,  as  closely  related  to 
sexual  development.  As  a  matter  of  fact,  kerosis  has  two  periods 
of  florescence,  that  of  the  genital  wave  at  the  time  of  birth,  and 
that  of  puberty;  and  a  period  of  decline,  when  sexual  life  is 
restricted. 

The  treatment  of  kerosis  must  consist  in  the  first  place  in  cor- 
recting all  hygienic  deficiencies  which  may  be  present.  It  may 
be  necessary  to  administer  alteratives,  such  as  phosphates,  cod- 
liver  oil  and  especially  arsenic  on  account  of  its  keratoplasty 
properties. 

Mineral  springs,  with  sulphur,  arsenic  or  sodium  chloride  water, 
are  especially  indicated. 

Locally,  sulphur  in  the  form  of  sulphurous  or  sulphur  lotions,  soaps, 
glycerolates,  pastes  or  salves,  but  also  the  tars,  camphor,  calomel, 
reducing  agents  in  general,  are  very  serviceable. 


198  KERATOSES 

With  perseverance,  it  will  almost  invariably  prove  possible  to 
obliterate  the  principal  kerotic  manifestations  and  to  restore  the 
skin,  if  not  to  normal,  at  least  to  a  condition  very  close  to  normal; 
relapses,  however,  are  common. 


PITYRIASIS    SIMPLEX. 

The  name  of  pityriasis  simplex  is  applied  to  a  non-inflammatory, 
scurfy,  bran-like  desquamation  of  the  horny  layer. 

The  term  pityriasis,  derived  from  the  Greek  irlrvpov  meaning 
"bran,"  is  on  the  other  hand  applied  to  various  pathological  con- 
ditions which  have  nothing  in  common  with  the  subject  under 
discussion. 

Pityriasis  versicolor  is  a  specific  parasitical  disease  of  the  epidermis; 
pityriasis  rosea  of  Gibert  is  an  erythemato-squamous  dermatosis; 
pityriasis  rubra  pilaris  belongs  rather  with  the  folliculoses;  pityriasis 
rubra  is  an  erythroderma. 

Pityriasis  simplex  must  be  distinguished  from  the  pityriasiform 
desquamations  following  upon  an  inflammation,  such  as  may  be 
observed  after  the  erythemas,  eruptive  fevers,  pyodermatitides, 
or  in  the  course  of  certain  trichophytoses  and  especially  of  eczemas. 
In  these  cases,  the  desquamation  almost  invariably  results  from 
the  phenomenon  known  as  parakeratosis. 

In  pityriasis  simplex,  on  the  contrary,  the  keratinization  of  the 
epidermis  is  complete,  and  takes  place,  at  least  apparently,  in  a 
normal  manner;  but  the  corneal  epithelium  is  thickened  and  peels 
off  in  scurfy  lamellae  or  scales,  instead  of  in  a  fine  powdery  and 
imperceptible  form  as  on  the  healthy  skin. 

In  accordance  with  this  definition,  pityriasis  simplex  is  one  of  tin- 
most  common  manifestations  or  consequences  of  kerosis.  Hence 
there  is  nothing  to  add  in  regard  to  its  etiology,  to  what  has  been 
stated  concerning  this  dystrophy;  but  I  wish  to  emphasize  again 
the  influence  of  age  upon  its  course. 

Those  authors  who  include  the  entire  picture  of  keratosis  under 
the  incorrect  name  of  "seborrhea,"  have  been  led,  after  Ilebra,  to 
consider  pityriasis  simplex  as  a  "seborrhea  sicca;"  but  this  expres- 
sion is  in  every  way  inadmissible. 

Pityriasis  simplex  is  almost  exclusively  met  with,  or  at  any  rate 
decidedly  predominates  in  the  hairy  regions  and  especially  on  the 
seal]),  where  it  is  designated  as  pityriasis  capitis.  Next  in  order,  it 
affects  the  beard,  the  pubis,  the  hairy  regions  of  the  thorax  and 
sometimes  the  limbs. 

Two  varieties  can  be  distinguished,  which  are  connected,  how- 
ever, by  a  series  of  intermediary  forms. 


PITYRIASIS  SIMPLEX  199 

Pityriasis  sicca  is  a  condition  in  which  there  is  an  incessant 
reproduction  of  dry  white  or  grayish  lamellae,  called  dandruff  by 
the  laity.  An  extreme  degree  was  formerly  described  as  "teigne 
amiantacee  (asbestos-like  tinea),  a  name  suggested  by  Alibert.  Its 
mild  degrees  blend  with  the  physiological  desquamation  which  is 
encountered  on  any  neglected  scalp  or  improperly  kept  beard  and 
even  on  the  entire  body  of  bedridden  patients. 

In  pityriasis  oleosa,  which  often  follows  upon  the  preceding,  the 
scales  are  oily,  greasy,  yellowish,  sticky;  but  it  is  noteworthy  that 
they  occur  on  a  skin  of  normal  coloration,  without  pathological 
redness. 

The  oily  character  of  this  pityriasis  might  appear  to  be  referable 
to  its  association  with  seborrhea  (supra-seborrheal  pityriasis  of 
Sabouraud).  This  combination  is  frequent,  but  not  constant. 
There  is  an  oily  pityriasis  without  seborrhea  in  the  same  location ; 
the  fat  is  derived  from  the  keratinization  itself. 

As  regards  the  steatoid  pityriasis  of  Sabouraud,  this  is  not  a 
simple  pityriasis,  but  an  eczematide  on  a  kerotic  soil.  It  furnishes 
no  scales,  but  crusts,  the  consistence  of  which  is  due  to  dried  serum; 
the  skin  where  they  occur  is  pink  and  moist  and  pruritus  is  often 
present.  The  so-called  milk-crusts  of  children  usually  belong  to  this 
variety. 

Although  we  are  not  justified,  in  my  opinion,  in  regarding  pity- 
riasis simplex  as  of  parasitical  origin,  it  is  necessary  to  point  out 
the  remarkable  abundance  of  microorganisms  in  its  scales.  The 
predominating  parasite  is  the  spore  of  Malassez,  or  bottle  bacillus; 
it  is  very  polymorphous,  rather  large,  assumes  the  forms  of 
yeasts,  but  has  so  far  resisted  all  attempts  at  artificial  culture.  It 
is  associated  with  the  bacillus  of  seborrhea  in  oily  pityriasis,  and 
with  various  cocci,  chiefly  the  polymorphous  coccus  of  the  skin 
(coccus  cutis  communis)  in  the  so-called  steatoid  pityriasis. 

Pityriasis  simplex  is  merely  an  unpleasant,  hardly  a  troublesome 
affection,  in  itself;  it  is  feared  only  on  account  of  the  alopecia  and 
baldness  which  are  attributed  to  it.  Aside  from  this,  it  exposes 
to  the  danger  of  eczematides  and  must  therefore  be  systematically 
controlled. 

The  treatment  of  pityriasis  capitis  requires  in  the  first  place  local 
measures;  frequent  washing  with  sulphur,  naphthol  or  tar-soaps, 
or  better  with  a  decoction  of  quillaya  bark  [saponin],  aqueous 
solutions  with  sulphur,  coal  tar,  etc.,  or  alcoholic  and  ethereal, 
mercurial,  naphtholated  or  compound  lotions,  several  formulae  for 
which  may  be  found  at  the  end  of  this  book.  Ointments  are  not 
agreeable  to  the  patient,  but  it  is  advisable  to  employ  them  in 
severe  cases,  at  least  for  nocturnal  treatment. 

The  general  hygiene  and  that  of  the  hair  and  its  arrangement 


200  KERATOSES 

must  be  properly  regulated.  Analogous  measures  are  applicable 
in  pityriasis  of  the  beard  or  other  regions. 

Pityriasis  Simplex  of  the  Face  and  Hairless  Parts  is  limited  to 
children  and  youthful  individuals  with  delicate  skins.  It  is  found 
around  the  mouth,  on  the  cheeks,  the  chin,  the  front  of  the  neck, 
and  sometimes  on  the  trunk  and  the  limbs.  It  appears  in  the  form 
of  rounded,  oval  spots  or  more  or  less  distinctly  outlined  polycyclic, 
scurfy  or  furfuraceous  areas,  with  a  normally  colored  or  slightly 
pinkish  surface,  ligher  than  the  background  when  the  complexion 
is  tanned  or  sun-burnt. 

This  superficial  dermatosis  is  contagious  and  even  epidemic  in 
groups  of  children.  It  may  coincide  with  impetigo  and  Sabouraud 
regards  it  as  a  dry  impetiginous  epidermatitis,  due  to  staphylococci. 
It  may  become  eczematized  and  should  probably  be  classified  with 
the  mild  eczematides. 

It  is  very  readily  curable  by  means  of  mild  sulphur  or  white 
precipitate  ointments,  etc. 

ICHTHYOSIS. 

Ichthyosis  is  a  diffuse  generalized  keratosis  which  is  never  con- 
genital but  which  manifests  itself  at  an  early  age  and  persists 
throughout  life.  It  is  usually  considered  a  malformation  of  the 
skin. 

Symptoms. — The  ichthyotic  skin  is  dry  and  scaly.  In  typical 
cases  of  moderate  severity,  the  integument  is  roughened,  parch- 
ment-like, covered  with  dry  scales  which  have  been  compared 
with  fish  scales;  they  are  thin,  white  or  brownish  or  gray,  more  or 
less  easily  detached  and  constantly  renewed. 

Many  degrees  or  objective  varieties  of  ichthyosis  can  be  described : 
In  xeroderma  the  skin  is  merely  dry  and  the  desquamation  is 
powdery,  almost  imperceptible;  "ichthyosis  nitida,  or  nacreous 
ichthyosis,  with  thin  and  silvery  lamelhe,  is  the  most  common  form; 
in  ichthyosis  nigricans  or  black  ichthyosis,  the  scales  are  of  a  dark 
color;  they  are  large  and  polygonal  in  ichthyosis  serpentina;  large, 
thick  and  resembling  the  skin  of  the  crocodile,  in  sauriasis;  finally,  in 
ichthyosis  hystrix,  prominent  warty  or  pointed  horny  excrescences 
are  seen,  suggestive  of  the  porcupine's  skin. 

The  two  last  named  varieties  are  sometimes  combined  under  the 
name  of  ichthyosis  cornea;  it  is  very  probable  that  they  do  not 
legitimately  belong  to  ichthyosis  but  to  the  ichthyosiform  hyper- 
keratoses, which  will  be  discussed  further  on. 

Ichthyosis  is  always  symmetrical  and  is  most  marked  on  the 
extensor  surface  of  the  limbs,  especially  the  elbows  and  knees  i  Fig. 
GO),  but  also  the  trunk  and  to  a  less  degree,  the  head  and  hands  and 


ICHTHYOSIS 


201 


feet.  The  face  is,  as  a  rule,  only  slightly  xerodermic;  the  scalp  is 
pityriasic;  the  palms  of  the  hands  and  the  soles  of  the  feet  are  very 
often  dry  and  wrinkled  like  the  hands  of  washerwomen. 

On  the  other  hand,  the  articular  folds,  axillae,  elbow  bends, 
popliteal  spaces,  intergluteal  fold,  groins  and  the  genital  organs 
are  always  more  or  less  free,  in  contradistinction  to  what  is  seen  in 
the  ichthyosiform  hyperkeratoses.  Lesions  of  mucous  membranes 
are  altogether  absent. 

On  passing  the  finger-nail  or  some  pointed  object  over  the  skin  of 
ichthyotic  patients,  a  white  powdery  track  is  left  behind;  the  skin 
often  appears  tense  and  when  it  is  grasped  between  two  fingers  the 
papillary  body  folds  up  superficially  over  the  derma.  The  hairy 
system  may  be  normal  or  is  imperfectly  developed;  the  downy 
hairs  of  the  extensor  surfaces  are  very  fine,  resembling  lanugo  and 
sometimes  appear  to  be  thinned;  the  co-existence  of  keratosis 
pilaris  is  invariable. 


Fig. 


-Ichthyos 


nitida  in  a  youth  aged  sixteen  years.    Note  the  white  mark  left 
by  the  garters  above  the  knees. 


The  nails  are  normal,  or  rarely  dry  and  brittle.  The  sebaceous 
and  sweat  secretions  are  greatly  diminished;  heat  or  violent  exer- 
cise may  cause  sweating  in  mild  cases  of  ichthyosis  and  the  affec- 
tion will  then  become  attenuated  or  disappear,  as  for  instance,  in 
the  summer.  Ichthyotic  patients  are  usually  thin,  poorly  devel- 
oped and  of  slight  resistance. 

Pruritus  is  not  a  feature  in  the  clinical  picture  of  ichthyosis, 
unless  it  is  complicated  by  eczema,  which  is  rather  common.  This 
eczematization  is  observed  especially  in  persons  neglectful  of 
cleanliness  and  those  exposed  to  artificial  dermatitis,  or  even,  it 
has  been  claimed,  without  an  apparent  local  cause;  the  attacks 
may  be  obstinate  and  recurrent  but  always  represent  merely  a- 
superadded  complication. 


202  KERATOSES 

Ichthyosis  is  never  strictly  congenital;  it  develops  gradually  and 
is  usually  not  observed  until  the  third  year  of  life,  though  some- 
times as  early  as  the  third  or  fourth  month;  often  the  date  of  onset 
cannot  be  accurately  determined.  It  may  become  attenuated  at 
the  time  of  puberty,  but  as  a  rule  it  persists  until  death.  Hebra 
and  Hardy  assert  that  it  may  disappear  after  eruptive  fevers,  but 
this  is  extremely  doubtful. 

The  name  of  ichthyosis  tabescentium,  desquamation  of  cachectics, 
and  senile  ichthyosis  has  been  applied  to  a  state  of  diffuse  atrophy, 
with  dryness  of  the  skin  and  ichthyosiform  desquamation,  which 
develops  in  weak  old  people  and  bedridden  invalids. 

It  is  not  known  if  the  pathological  condition  in  these  cases  is 
always  identical  and  how  it  is  related  to  ordinary  ichthyosis. 

Pathological  Anatomy. — The  horny  layer  is  always  more  or  less 
thickened;  the  granular  layer  is  diminished  or  absent  in  the  variety 
nitida,  but  there  is  no  complete  parakeratosis;  the  mucous  body 
is  rather  thin  and  tense.  The  papillae  are  less  developed  than 
normal.  The  papillary  body  and  the  chorion  are  almost  invariably 
found  to  contain  a  moderate  infiltration  of  round  cells  and  mast 
cells  around  the  vessels;  this  fact  has  led  Unna  and  Tommasoli  to 
consider  ichthyosis  as  an  inflammatory  skin  disease.  The  pilo- 
sebaceous  follicles  present  the  lesions  of  keratosis  pilaris.  Various 
lesions  of  the  sweat  glands  have  been  reported. 

The  changes  attributed  to  the  hystrix  form  are  identical  with  those 
of  ichthyosiform  hyperkeratosis  and  of  the  hyperkeratotic  nevi;  so 
that  some  doubt  prevails  as  to  the  existence  of  a  true  ichthyosis 
hystrix. 

Etiology. — Ichthyosis,  except  in  its  mildest  form,  is  not  very 
common;  its  extreme  degrees  are  actually  rare.  It  is  a  hereditary 
malformation  in  one-fourth  of  the  cases,  familial  in  one-half  of 
the  cases,  according  to  Gassmann;  the  transmission  is  irregular 
and  may  skip  a  generation.  It  is  not  certain  and  even  rather 
improbable  that  alcoholism,  syphilis  or  tuberculosis  of  the  parents 
create  a  predisposition  to  the  disease.  Both  sexes  are  equally 
affected. 

Diagnosis.  —  Mild  xeroderma  with  or  without  keratosis  pilaris, 
may  be  misinterpreted  or  confused  on  superficial  examination 
with  pityriasis  simplex,  kerosis,  the  post-eruptive  desquamations, 
desquamations  of  cachectics,  etc.  When  the  onset  of  the  affection 
can  be  determined,  the  point  will  be  settled  at  once. 

In  psoriasis,  in  the  dry  eczemas  and  in  pityriasis  pilaris,  the  skin  is 
red.  Psorospermosis,  named  ichthyosis  follicularis  by  J.  C.  White, 
is  quite  characteristic. 

Ichthyosis  must  be  differentiated  especially  from  generalized 
ichthyosiform    hyperkeratosis    (congenital    ichthyosis    of    certain 


ICHTHYOSIFORM  HYPERKERATOSES  203 

authors),  and  from  regional  or  very  extensive  systematized  hyper- 
keratotic  new,,  many  cases  of  which  have  been  described  under  the 
names  of  ichthyosis  partialis,  ichthyosis  hystrix,  etc. 

Treatment. — Although  the  disease  is  incurable,  the  patients  can 
be  greatly  relieved  by  maintaining  their  skin  in  a  clean  and  supple 
condition.  Arsenic  seems  to  be  of  little  use;  cod-liver  oil  is  to  be 
recommended;  thyroid  medication  may  be  cautiously  tried. 

The  external  treatment,  however,  is  of  the  greatest  importance. 
Repeated  and  prolonged  baths,  washing  with  soap,  steam  baths, 
on  the  one  hand  and  daily  inunctions  with  vaseline,  glycerin,  fatty 
substances  or  various  salves,  on  the  other,  will  give  the  skin  in  a 
short  time  a  nearly  normal  appearance  in  cases  of  moderately 
severe  ichthyosis.  The  same  measures  must  be  insisted  upon  in  the 
severe  types.  It  is  necessary  to  regulate  the  treatment  in  a  given 
case  in  such  a  way  as  to  keep  up  the  results  attained. 

ICHTHYOSIFORM   HYPERKERATOSES. 

Under  this  heading  must  be  grouped  some  interrelated  dermatoses 
which  differ  from  ichthyosis  by  the  following  characteristics: 

They  may  be  strictly  congenital  or  their  appearance  may  be 
delayed  for  a  shorter  or  longer  time  after  birth;  they  usually  take 
a  progressive  course;  hyperkeratosis  is  more  pronounced  than  is 
ichthyosis  and  is  accompanied  by  a  marked  redness  of  the  skin 
which  has  led  to  the  name  of  ichthyosiform  erythroderma;  anidrosis  is 
absent  or  may  be  actually  replaced  by  hyperidrosis ;  far  from  spar- 
ing the  articular  folds,  the  lesions  on  the  contrary  are  especially 
well  developed  in  these  regions;  their  histological  structure  is  alto- 
gether different. 

A  distinction  is  made  between  a  generalized  form,  to  be  described 
next,  and  circumscribed  forms,  which  will  be  discussed  in  the 
succeeding  paragraphs. 

Generalized  Ichthyosiform  Hyperkeratosis. — This  is  often  named 
fetal,  intra-uterine  or  congenital  ichthyosis,  for  it  is  always  present 
at  the  time  of  birth.  Two  degrees  of  the  affection  may  be  dis- 
tinguished. 

The  severe  type  is  incompatible  with  life;  it  has  been  referred  to 
in  the  chapter  on  the  erythrodermias.  It  represents  a  diffuse  con- 
genital malignant  keratoma. 

The  benign  type,  distinctly  separated  from  ichthyosis  by  Unna 
under  the  name  of  congenital  hyperkeratosis,  is  characterized  by  a 
more  or  less  severe  and  universal  redness  of  the  skin  which  is  con- 
tracted and  covered  with  large  thick,  polygonal,  brownish  scales 
resembling  the  scales  of  sauriasis,  very  adherent,  but  capable  of 
being  detached  in  a  single  piece  by  traction  or  maceration  (Fig.  61). 


204 


KERATOSES 


The  face  is  affected;  it  is  pinkish  and  scaly;  ectropion  is  usually 
present.  The  articular  folds  are  the  seat  of  horny,  blackish, 
papillary  excrescences.  The  palmar  and  plantar  regions  present 
the  appearance  of  hereditary  keratoderma.  The  hairy  scalp  is 
covered  with   a  sebaceous  coat.     Brocq  observed  that  in  certain 


I  [G.  61.     <  generalized 
Note   the  lizard-like  aspect    oi     the 
popliteal  spaces. 


■perkeratosis  in  a  girl  aged  eight  years, 
[tegument   and  the  horny  vegetations  in  the 


cases,  which  he  calls  ichthyosiform  congenital  erythroderma  with 
hyper-epidermatro/phy,  the  hairs  and  nails  grow  two  or  three  times 
as  rapidly  as  in  normal  individuals. 

Especially  in  the  first  years,  occasional  crops  of  bullae  may  be 
observed  on  the  limbs  and  on  the  trunk;  I  have  shown  that  these 
bullae   are   auto-inoculable;    they   probably   represent   merely    an 


ICHTH  YOSIFORM  H  YPERKERA  TOSES 


205 


impetigo,  favored  by  the  cracking  of  the  epidermis  (Fig.  62).  All 
the  symptoms,  especially  the  redness,  become  attenuated  with  age. 
The  majority  of  cases  described  under  the  names  of  ichthyosis 
cornea,  sauriasis,  ichthyosis  hystrix,  were  in  reality  ichthyosiform 
hyperkeratosis. 


Fig.  62. — Generalized  ichthyosiform  hyperkeratosis  in  a  boy  aged  thirteen  years. 
External  surface  of  right  knee.  The  horny  verrucous  covering  has  been  detached  in 
places;  at  the  level  of  the  head  of  the  fibula  a  bulla  is  seen,  resulting  from  an  experi- 
mental auto-inoculation. 


The  pathological  anatomy  shows  lesions  altogether  different  from 
those  of  ichthyosis.  The  horny  layer  is  enormously  thickened  and 
arranged  like  shingles  on  the  acuminate  protuberances;  it  contains 
considerably  less  fat  than  in  the  normal  condition.  The  granular 
layer  is  markedly  hypertrophied.  The  rete  is  thickened.  The  papillse 
are  greatly  elongated  and  irregular.  Perivascular  infiltration  is  not 
constant. 

Partial  Ichthyosiform  Hyperkeratoses. — Clinical  observation 
and  histology  are  in  accord  as  to  the  relation  with  ichthyosiform 
hyperkeratosis,  of  familial  keratoderma  or  Meleda  disease,  which 
seems  to  represent  merely  a  regional  and  partial  variety  of  this 
affection  (p.  211). 

Notwithstanding  its  very  remarkable  course,  it  seems  justifiable 
to  connect  with  ichthyosiform  hyperkeratosis  also  the  rare  disease 
symmetrical  erythrokeratoderma,  especially  since  it  may  become 
associated  with  familial  keratoderma  (Brocq  and  Dubreuilh). 


206  KERATOSES 

This  uncommon  skin  affection,  a  typical  case  of  which  was  re- 
ported by  me  in  1911,  the  face  and  upper  part  of  the  trunk  alone 
escaping,  appears  after  birth  in  the  form  of  spots  or  isolated  patches 
which  spread  rather  rapidly  and  finally  invade  almost  the  entire 
internment;  the  keratotic  surfaces  may  become  warty  and  give  rise 
to  genuine  cutaneous  horns. 

All  the  hyperkeratoses  of  this  group,  generalized  or  circum- 
scribed, probably  represent  cutaneous  malformations  of  the  same 
kind  as  nevi;  their  sometimes  delayed  appearance,  their  symmetry 
and  their  extensive  character,  do  not  militate  against  this  view. 
There  are  reasons  for  the  belief  that  consanguinity  of  the  parents 
and  heredity  play  a  certain  part  in  their  etiology. 

CIRCUMSCRIBED  KERATOSES. 

Keratotic  Nevi. — As  with  nevi  in  general,  these  may  exist  at  birth, 
or  develop  in  the  course  of  childhood  or  even  later.  They  appear 
in  the  form  of  spots,  elevations  or  verrucosities  which  gradually 
become  covered  with  a  more  or  less  thick  coating  of  horny  tissue. 

Hyperkeratotic  and  Varicose  Nevi. — Hyperkeratotic  and  varicose 
nevi  may  be  single  or  multiple,  limited  or  very  extensive,  situated 
at  any  point  of  the  integument.  Some  are  regional  and  occasionally 
symmetrical,  occupying  for  example  certain  articular  folds.  Others 
are  covered  with  such  a  thick  accumulation  of  horny  substance  as 
to  constitute  a  genuine  cutaneous  horn,  resembling  a  small  ram's 
horn. 

Linear  Nevi. — Linear  nevi  constitute  a  very  peculiar  systema- 
tized form  of  hyperkeratotic  nevi.  The  verrucosities,  of  a  gray, 
brown  or  black  color,  are  arranged  in  continuous  or  interrupted 
streaks  of  great  length  and  variable  width,  often  in  very  regular 
patterns.  Sometimes  unilateral,  in  other  cases  symmetrical,  these 
nevi  are  made  up  by  a  single  streak  or  several  streaks  following  a 
parallel  course.  I  have  repeatedly  observed  the  entire  body,  includ- 
ing the  limbs  and  the  face,  to  be  covered  by  linear  designs  of  this 
kind  (Fig.  I'm).  On  the  limbs  the  streaks  are  longitudinal,  often 
partially  spiral.  On  the  trunk,  they  are  horizontal  or  rather  oblique 
and  frequently  present  angular  inflections,  forward  and  backward, 
in  the  vicinity  of  the  middle  line,  which  itself  maybe  traced  by  a 
streak.  In  the  face,  the  lines  are  orbicular  or  radiating  in  various 
directions. 

An  explanation  of  these  distributions  which  do  not  seem  to  be 
the  result  of  accident,  has  taxed  the  ingenuity  of  observers.  The 
direction  of  the  streaks  has  been  referred  to  that  of  the  nerves;  to  the 
lines  of  Voigt,  separating  the  nerve  territories;  to  the  lines  of  cleavage 
of  the  skin;  to  the  course  of  the  bloodvessels;  to  the  metameric 


CIRCUMSCRIBED  KERATOSES 


207 


zones  of  Head;  to  the  lines  of  fusion  of  the  embryonic  clefts;  finally, 
to  stretching  of  cell-groups  in  the  course  of  embryonic  growth. 

None  of  these  theories  explains  all  the  arrangements  which  have 
been  noted;  and  the  terms  of  nervous,  zoniform,  metameric,  uni- 
lateral, etc.,  nevi,  are  not  justified.  The  same  remark  applies  to  the 
term  ichthyosis  hystrix. 


Fig. 


-Linear  hyperkeratotic  nevi,  very  numerous,  in  a  girl  aged  seven  years. 
Service  of  Dr.  Variot. 


The  linear  nevi,  instead  of  being  hyperkeratotic,  may  suggest 
simple  papilloma,  psoriasis,  or  lichen;  they  may  be  hairy,  pig- 
mentary and  so  forth. 

Not  all  linear  dermatoses  are  necessarily  nevi;  in  rare  instances, 
genuine  cases  of    lichen    planus,   psoriasis,   eczematides,   prurigo 


208  KERATOSES 

vulgaris,  etc.,  are  observed  which  assume  a  topography  like  the 
linear  nevi,  appearing  at  any  age  and  subsiding  on  appropriate 
treatment. 

Flat  Senile  Warts  (Verruca  Plana  Senilis). — These  keratotic  ele- 
vations, also  known  as  seborrheal  warts,  have  the  following  char- 
acteristics: 

They  are  rounded  or  oval,  sometimes  irregular,  from  the  size  of 
a  lentil  to  that  of  a  green  almond,  more  prominent  in  the  center 
than  at  the  periphery,  distinctly  circumscribed,  sometimes  actually 
overhanging,  covered  with  an  adherent  horny  and  fatty  layer,  of 
variable  thickness,  of  a  gray,  brown  or  black  color.  After  this  coat 
lias  been  removed  by  washing  with  soap,  maceration,  or  rubbing 
with  ether,  a  mammillated,  honeycomb  or  cauliflower-like  sur- 
face with  furrows  is  exposed;  the  consistence  is  molluscoid  or 
granular. 

Senile  warts,  generally  numerous  on  the  same  individual,  pre- 
ferably occupy  the  flanks,  the  belt-line,  the  back,  the  chest,  the 
neck,  the  shoulders;  many  hundreds  of  them  may  be  counted;  they 
are  less  frequently  observed  on  the  forehead,  the  temples  and  the 
cheeks.  They  develop  after  the  fortieth  year  of  life,  especially  in 
women;  they  may  begin  before  the  age  of  thirty.  They  persist  and 
multiply  with  the  advance  of  years. 

Histology  shows  either  hypertrophy  of  the  epidermis  or  atrophy 
through  invasion  of  the  horny  layer,  but  always  some  irregu- 
larity; the  papillae  are  deformed  and  twisted.  Horny  pearls  are 
often  found  in  the  interpapillary  depressions.  A  special  lesion, 
described  by  Pollitzer,  consists  in  a  peculiar  arrangement  in  whorls 
of  the  Malpighian  cells  at  certain  parts.  The  hairs  and  glands  are 
atrophied;  there  is  no  true  seborrhea.  The  subjacent  cutis  is  often 
in  a  state  of  senile  degeneration,  but  presents  no  inflammatory 
infiltration. 

Their  clinical  features,  their  structure  and  their  seat,  everything 
differentiates  senile  warts  from  the  patches  of  senile  keratosis  with 
which  they  are  too  often  confused.  They  have  not  the  same  tendency 
as  the  latter  to  undergo  epitheliomatous  transformation. 

I  consider  them  as  delayed  nevi,  and  they  actually  coincide 
frequently  with  vascular  nevi,  fibroma  molluscum,  or  pigmentary 
spots.  There  is  no  connection  as  regards  etiology  and  character 
between  senile  warts  and  ordinary  warts. 

Treatment  is  instituted  only  on  special  request;  mercurial  oint- 
ments, collodimn  with  salicylates  or  sublimate,  black  wash  and  even 
strong  caustic  agents  may  be  recommended.  It  is  much  more  advis- 
able, however,  to  resort  to  the  galvanocautery  cautiously  handled 
and  combined  if  necessary  with  curettage;  no  perceptible  cicatrix 
must  be  produced.     Radiotherapy  seemed  to  me  to  be  inefficient. 


CIRCUMSCRIBED  KERATOSES  209 

Electrolysis  is  very  successful,  but  the  method  is  much  too  laborious 
in  its  application.  [Destruction  by  means  of  carbonic  acid  snow  may 
be  employed.] 

Keratosis  Senilis. — The  usually  multiple  and  scattered  keratotic 
spots  which  are  observed  especially  on  the  face  of  aged  individuals, 
were  formerly  known  under  the  names  of  "crasse  des  vieillards" 
acne  sebacee,  etc.  They  seem  to  me  to  constitute  a  complication 
of  senile  degeneration  of  the  skin  and  frequently  lead  to  multiple 
epitheliomatosis  (p.  685) ;  from  this  viewpoint,  they  constitute  an 
obvious  type  of  precancerous  dermatosis. 


A 

B       r 

i        1 

; 

D 

) 

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-v---:  - 

-^ 

-W 

p^att 

,  'Wr-'  \ 

Si 

-  "J  *     <      i 

-■:<<,:■'■        :\£S^ 

'•=.' 

Mr 

i                .                    '" 

\ 

1%     ■  • 

F 

Sir 

G 

1 

H 

I, 

.  tiAfV** 

Fig.  64. — Histology  of  senile  keratosis.  The  section  comprises  the  border  of 
a  fairly  extensive  keratotic  spot  from  the  temporal  region  of  an  old  man.  A, 
edema;  B,  epidermic  globe;  C,  hyperkeratosis;  D,  sebaceous  gland;  E,  elacin;  F,  hair 
follicle;  G,  plasmatic  infiltrate;  H,  elacin;  I,  plasmatic  infiltrate.      X  37. 

The  lesions  of  senile  keratosis  begin  as  dry  yellowish  or  brownish 
spots,  or  as  warty  elevations  somewhat  resembling  seborrheal 
warts,  or  again  as  irregular  but  fairly  well  outlined  telangiectatic 
red  spots.  Gradually  they  become  covered  with  a  gray  or  brownish 
keratotic  coat,  friable  or  of  dry  consistence,  with  a  wrinkled  surface 
which  may  bristle  with  irregular  elevations.  This  very  adherent 
keratotic  layer  sends  conical  processes  into  the  derma;  its  detach- 
ment often  gives  rise  to  small  hemorrhages;  the  changes  become  less 
marked  toward  the  borders  of  the  spots;  the  skin  in  their  center 
may  be  atrophic  or  cicatricial. 
14 


210  KERATOSES 

Senile  keratoses  appear  more  or  less  soon  after  the  fiftieth  year  in 
very  variable  numbers,  notably  on  the  forehead,  temples,  nose, 
cheeks,  the  back  of  the  hands  and  wrists,  sometimes  on  the  neck 
and  the  forearms.  As  a  rule,  they  persist  indefinitely  and  increase 
in  number,  but  they  may  disappear. 

Their  evolution  into  epithelioma  is  by  no  means  necessarily  fatal. 
This  is  indicated  by  a  transformation  of  the  keratotic  layer  into  a 
crust,  ulceration  of  the  subjacent  derma,  at  first  superficial,  and 
the  appearance  of  epitheliomatous  pearls  at  the  circumference. 

Histology  shows  in  the  first  stages  an  irregular  hyperkeratotic 
horny  layer,  provided  with  conical  processes  on  its  inferior  sur- 
face; a  thinned  mucous  body,  sometimes  infiltrated  with  wander- 
ing cells;  an  irregular  and  edematous  papillary  body.  The  corium 
presents  to  a  high  degree  the  lesions  of  senile  dystrophy,  namely 
the  transformation  of  the  elastic  tissue  into  basophilic  elacin,  and 
a  colloid  change  of  the  connective-tissue  strands;  perivascular  tracks 
of  cellular  infiltration  are  seen,  with  a  predominance  of  plasmocvtes 
(Fig.  64). 

The  differential  diagnosis  must  be  made  from  the  various  nevi, 
syphilides,  psoriasis,  rosacea,  especially  from  lupus  erythermatodes. 
The  patient's  age  and  the  location  of  the  lesions  are  factors  of 
prime  importance. 

Treatment  with  salves  and  ointments  containing  keratolytic  and 
keratoplastic  medicinal  agents  is  often  not  particularly  efficient. 
Radiotherapy  accomplishes  frequently,  though  not  invariably,  a 
complete  disappearance  without  pain.  The  galvano-cautery,  assisted 
by  curettage,  yields  excellent  results. 

In  presenile  dystrophy,  in  xeroderma  pigmentosum,  in  radioder- 
matitis,  and  in  cutaneous  arsenic  poisoning,  practically  identical 
keratoses  in  spots  and  warty  elevations  may  occur;  these  dystro- 
phies belong  to  the  same  natural  group. 

Gonococcal  Keratoma. — A  very  rare  variety  of  disseminated 
keratosis  has  been  described  under  the  name  of  "  blennorrhagic 
keratoma"  by  Yidal,  Jacquet,  Jeanselme,  Chauffard,  and  others. 
Certain  cases  of  gonorrhea,  confined  to  bed  on  account  of  severe 
arthropathies  or  myelopathies,  present  hard  yellowish  conical 
elevations,  comparable  to  drops  of  yellow  wax  or  upholsterer's 
tacks,  scattered  over  the  limbs  and  sometimes  on  the  trunk.  There 
may  be  an  erythematous  border  at  the  circumference. 

Genuine  carapaces  of  hyperkeratosis  have  been  observed  in  the 
palmar  and  plantar  regions.  These  products  disappear  in  two  or 
three  months  under  simple  attention  to  cleanliness. 

Porokeratosis.— The  porokeratosis  of  Mibelli  (1893)  and  Respighi 
is  a  rare  affection,  characterized  by  irregular  circulate  spots,  the 
area  of  which  is  atrophic,  scaly  or  normal,  with  a  papular  border 


KERATODERMA  211 

marked  by  a  horny  plate;  this  plate  is  imbedded  in  a  "trench,"  or 
groove  from  which  it  rises  in  the  form  of  a  prismatic  crest.  The 
lesion  begins  with  a  horny  cone  wedged  in  a  papule  which  slowly 
spreads  out.  The  lesions  are  situated  especially  on  the  extremities, 
the  face  and  the  genitals;  they  have  been  observed  in  the  buccal 
mucosa. 

Porakeratosis  is  often  familial,  but  nothing  more  is  known  con- 
cerning its  etiology.  Truffi  associates  it  with  the  nevi.  Mibelli 
assumes  a  primary  epidermal  dystrophy  of  the  glandular  orifices, 
more  particularly  of  the  sweat-pores. 

The  porokeratosis  of  Italian  authors  must  not  be  confused  with 
the  punctiform  keratosis  which  will  be  briefly  referred  to  in-the  fol- 
lowing and  which  the  majority  of  writers  also  call  porokeratosis. 

KERATODERMA. 

I  employ  the  term  keratoderma  for  the  palmar  and  plantar 
keratoses. 

The  skin  of  the  palmar  and  plantar  regions  has  a  special  structure. 
It  is  predisposed  to  hyperkeratosis  and  in  this  case  has  a  tendency  to 
crack,  forming  very  painful  fissures  in  the  flexion  folds.  All  dry 
dermatoses  in  this  locality  assume  an  analogous  appearance,  which 
renders  the  diagnosis  rather  difficult. 

Some  keratodermas  are  essential,  representing  malformations; 
others  are  symptomatic,  the  result  of  repeated  traumatisms,  intoxi- 
cations or  localization  of  various  dermatoses. 

Essential  Keratodermas. — Familial  keratoderma,  or  Meleda  disease 
[keratoma  palmare  et  plantare]  is  an  ordinarily  congenital,  some- 
times acquired  affection,  which  frequently  attacks  several  chil- 
dren of  the  same  family  and  has  a  marked  tendency  to  hereditary 
transmission. 

The  palmar  aspect  of  the  hands  and  fingers  (Fig.  65),  the  plantar 
aspect  of  the  feet  and  toes,  are  symmetrically  and  as  a  whole,  the 
seat  of  a  horny  thickening.  The  borders  are  marked  by  a  purplish 
or  bluish-pink  edge  from  4  to  5  mm.  wide. 

The  hyperplastic  horny  layer  may  be  smooth,  soft,  of  a  waxy 
or  brownish-yellow  hue,  made  up  of  large  very  adherent  lamellae. 
In  this  case  a  local  hyperidrosis  is  frequently  noted  which  is  regarded 
by  Lenglet  as  the  initial  phenomenon  and  the  hyperkeratosis  itself 
is  supposed  to  originate  at  the  sweat  orifices.  I  have  sometimes 
noted  the  presence  of  intracorneal  bullae  with  turbid  contents. 

In  other  cases,  the  hyperkeratosis  is  dry,  hard,  roughened,  of  a 
thickness  which  may  reach  a  centimeter ;  it  is  fissured  in  the  folds, 
or  divided  into  polygonal  blocks. 

The  underlying  skin  is  invariably  red,  usually  tense,  sclerotic 


212 


KERATOSES 


and  atrophic  Tn  well-marked  forms,  it  is  so  much  retracted  at  the 
last  phalanges  that  the  fingers  arc  conical  and  tapering,  as  if  enclosed 
in  a  very  tight-fitting,  yellowish  and  horny  case;  the  nails  are 
thinned  and  the  nail  bed  is  bloodless. 

The  movements  of  the  hands  and  fingers  are  impeded  and  painful; 
walking  is  difficult. 

The  lesions  almost  invariably  encroach  upon  the  anterior  aspect 
of  the  wri>t>  and  along  the  Achilles  tendons;  the  knees,  elbows  and 
articular  folds  may  present  thick,  warty,  aberrant  patches,  of  a 
brownish-red  color,  distinctly  circumscribed,  with  dilated  and 
blackened  pores.  These  patches  may  progress  and  extend,  as 
shown  by  casts  preserved  in  the  Museum  of  the  St.  Louis  Hospital, 
taken  at  intervals  of  ten  years  on  the  same  patient. 


Fig.  65.     Hand  of 


ing  girl,  aged  thirteen  years,  with  congenital  symmetric 
palmar  and  plantar  keratoderma. 


Familial  keratoderma  is  met  with  either  isolated,  or  associated 
with  generalized  ichthyosiform  hyperkeratosis,  of  which  itrepresents 
merely  a  localized  variety;  in  its  course  it  resembles  symmetrical 
erythrokeratoderma  with  which  it  may  coincide. 

When  essential  keratoderma  is  not  strictly  congenital,  it  may 
develop  between  the  first  months  of  life  and  the  second  year,  or 
even  in  late  childhood.  The  onset  is  not  easily  discovered;  it  is 
preceded  by  redness,  hyperidrosis  and  exfoliation  in  hue  lamellae. 

The  cases  of  delayed  appearance  are  distinguished  by  several 
authors  under  the  name  of  symmetrical  keratoderma  of  adults, 
acrok'erai  'inn,  or  essential  tylosis.  The  term  of  M61eda  disease  comes 
from  an  island  in  the  Adriatic,  where  Neumann  and  Killers  found 
this  malformation  to  be  endemic.  In  the  non-hereditary  cases,  the 
origin  has  been  referred  to  consanguinity  of  the  parents. 


KERATODERMA  213 

Palmar  hyperkeratosis  is  serious  on  account  of  its  incurable 
character  and  the  resulting  inconvenience,  but  the  condition  is 
considerably  relieved  by  moist  or  rubberized  dressings  and  by  kera- 
tolytic  agents.  Radiotherapy,  which  constitutes  the  best  treatment, 
has  led  to  noteworthy  improvement,  but  to  no  complete  cure  in 
my  experience. 

Symptomatic  Keratodermas. — Occupational  Keratoderma. — This 
results  from  friction,  pressure  or  various  physical  and  chemical, 
chronically  repeated  irritants,  and  represents  a  sort  of  diffuse  callus. 
The  lesions  are  unilateral  or  symmetrical  and  their  distribution  is 
often  characteristic  of  certain  occupations. 


Fig.  66. — Arsenical  keratosis.  The  illustration  shows  keratotic  patches,  similar 
in  type  to  others  situated  over  the  forearms,  face,  scrotum  and  legs,  interspersed  with 
hyperpigmentations  and  several  true  epitheliomata.  In  addition,  there  occurred  a 
symmetrical  keratoderma  of  the  palms  and  soles.  The  disease  was  of  twenty-five 
years'  duration  and  due  to  drinking  water  charged  with  arsenic.     (Ormsby.) 

Arsenical  Keratosis. — Arsenical  keratosis,  a  consequence  of 
chronic  arsenic  poisoning,  is  localized  especially  on  the  hands  and 
feet.  It  is  often  preceded  by  formication  and  attacks  of  desqua- 
mative or  bullous  erythema.  It  persists  indefinitely,  even  if  the 
arsenic  medication  is  stopped. 

It  manifests  itself  under  two  forms  which  are  sometimes  asso- 
ciated: (1)  A  diffuse  yellowish  scurfy  thickening  of  the  palmar  and 
plantar  regions,  with  well-marked  papillary  crests;  (2)  verrucous 
protuberances  which  occur  in  large  numbers  on  both  surfaces  of 


214 


KERATOSES 


tli 


the  extremities,  sometimes  also  the  face  and  neck  and  which  may 
degenerate  into  arsenical  cancer. 

Eczema  Keratoticum. — The  most  common  kerato 
referable  to  eczema  and  to  syphilis. 

Keratotic  eczema  or  corneal  eczema  of  Wilson 
metrical  and  often  of  occupational  origin.  It  may  be  partial  or 
extend  over  almost  the  entire  region  (Fig.  67)  and  is  characterized 
by  its  diffuse  imperfectly  marked  borders  which  pass  imperceptibly 


nas  are  Those 


is  usually  svm- 


I'hnt.'ir  kcfiiliitic  cc/.cnm. 


into  the  healthy  skin.  It  has  a  tendency  to  spread  along  the  large 
grooves.  The  thickened  horny  layer  splits  and  becomes  exfoliated 
in  lamella1,  exposing  a  reddened  skin,  where  vesicles  are  rarely 
observed.  The  histological  lesions  are  those  of  eczema.  Foci  of 
eczema  or  eczematides,  are  encountered  elsewhere,  especially  on  the 
scalp.  The  duration  of  this  affection  is  sometimes  several  years, 
with  remissions  and  relapses.    It  is  treated  with  keratolytic  agents 


KERATODERMA 


21! 


followed    by    reducing   agents;    radiotherapy    is    sometimes   very 
effective. 

Palmar  and  Plantar  Psoriasis. — Palmar  and  plantar  psoriasis  is 
usually  symmetrical  and  accompanied  by  a  scattered  eruption,  but 
it  may  be  isolated,  affecting  only  a  single  extremity.  It  consists 
at  the  onset  of  hyperkeratotic  yellowish  spots  which  are  distinctly 
outlined  and  promptly  become  exfoliated  in  dry,  friable  lamellse 
under  which  the  bright  red  skin  is  seen.     The  spots  which  have 


Fig.  68. — Genuine  palmar  psoriasis. 

rounded  and  clearly  outlined  contours  become  confluent  in  poly- 
cyclic  patches  (Fig.  68).  The  appearance  may  be  extremely  sug- 
gestive of  syphilis  or  trichophytosis,  but  it  is  rare  for  these  spots 
not  to  extend,  as  manifest  patches  of  psoriasis,  to  the  wrists  or  to  the 
dorsal  regions  of  the  hand,  the  fingers,  or  the  feet,  or  for  no  other 
spots  to  appear  in  different  parts  of  the  integument — which  clinches 
the  diagnosis.  Biopsy  shows  the  characteristic  lesions  of  psoriasis. 
In  this  particular  localization,  psoriasis  requires  very  energetic 
treatment;  sometimes  it  subsides  spontaneously. 


21G  KERATOSES 

In  pityriasis  rubra  pilaris,  the  palms  and  soles  are  diffusely  red- 
dened, dry,  hyperkeratotic  and  thickened,  but  desquamation  is 
slight. 

Lichen  planus  gives  rise  either  to  small,  dry,  horny  papules,  or  to 
depressed  more  or  less  confluent  keratotic  spots  (Fig.  23),  or  to  red 
and  finely  scaly  patches — or  finally  to  total  keratoderma. 

Gonococcal  Keratoderma. — Gonococcal  keratoderma  manifests 
itself  in  the  form  of  horny  soles,  sometimes  a  centimeter  thick,  or  as 
hyperkeratotic  or  crusted  acuminate  papules,  surrounded  by  a  dark 
red  halo;  it  affects  the  plantar  and  palmar  regions,  the  back  of  the 
feet,  the  lower  limbs,  sometimes  the  genitals  and  exceptionally 
the  upper  limbs  and  the  trunk.  This  affection,  which  is  very 
uncommon,  has  been  observed  especially  in  connection  with  gono- 
coccal rheumatism. 

Palmar  and  plantar  trichophytosis,  elucidated  by  the  work  of 
Djellaleddin  Moukhtar,  is  not,  strictly  speaking,  a  keratoderma,  but 
must  be  mentioned  from  the  diagnostic  viewpoint.  It  appears  as 
perfectly  round  or  polycyclic  red  spots,  surrounded  by  an  epidermic 
collar.  Small  vesicles  may  be  discovered  on  their  area  and  around 
their  circumference.  The  mycelium  is  abundantly  present  in  the 
vesicular  fluid  and  in  the  scales. 

Epidermophytosis  of  the  same  regions,  more  recently  discovered, 
is  relatively  frequent  and  presents  a  variety  of  aspects.  It  is  there- 
fore essential  to  keep  in  mind  the  imperative  necessity  of  micro- 
scopical examination  in  all  more  or  less  doubtful  cases. 

The  reader  is  reminded  that  in  the  course  of  dysidrosis,  or  of  the 
pyodermatitides  which  are  sometimes  so  obstinate  in  the  palmar 
and  plantar  regions  (continuous-  acrodermatitis),  a  clinical  picture 
suggestive  of  various  keratodermas  is  sometimes  seen. 

The  appearance  of  so-called  punctiform  keratosis  (porokeratosis 
of  some  writers),  characterized  by  small,  sometimes  very  hard, 
scattered  or  grouped,  miliary  horny  masses,  may  be  produced,  with 
slightly  variable  modifications,  by  an  entire  series  of  skin  affections : 
lichen  planus,  follicular  dyskeratosis,  warts,  keratotic  nevi,  familial 
or  arsenical  keratoderma,  etc. 

The  psoriatiform  palmar  and  plantar  syphilides,  also  erroneously 
named  syphilitic  psoriasis  by  some  authors,  are  the  most  important 
of  all  the  keratodermas.  Bazin  grouped  nearly  all  the  lesions 
enumerated  above  under  the  heading  of  palmar  arthritides,  in  order 
to  contrast  them  with  syphilides  in  the  same  locality. 

These  syphilides  are  relatively  common,  they  may  appear  at  any 
date  between  the  third  month  following  the  infection  and  the  most 
remote  tertiary  stages.  They  resemble  each  other  so  closely  that  it 
is  not  always  possible  to  distinguish  the  premature  from  the  late 
forms;  the  latter  are  described  by  A.  Fournier  as  "delayed  secondary 


KERATODERMA  217 

manifestations."  Nevertheless,  although  certain  pictures  do  not 
indicate  the  age  of  the  syphilitic  infection,  there  are  others  belonging- 
more  particularly  to  one  or  other  of  its  stages. 

In  the  secondary  stage,  multiple  lesions  are  especially  met  with, 
consisting  either  of  flat  lenticular  papules  of  a  dusky  red  color,  slightly 
keratotic  and  scaly,  or  of  depressed  nummular  spots,  surrounded  by 
a  keratotic  ridge  (Fig.  69) ;  in  the  tertiary  stage  and  in  hereditary 
syphilis  tarda,  round  or  polycyclic  spots  of  a  dark  or  coppery 


H^^Hjiji^fj^gJnj^^^H 


Fig.  69. — Early  secondary  palmar  syphilide,  contemporaneous  with  the  roseola. 

red,  single  or  in  small  numbers,  are  more  usually  seen,  which  may 
be  markedly  hyperkeratotic,  or  wrinkled  and  cracked,  sometimes 
bordered  by  tubercles  (Fig.  70). 

These  various  lesions  are  found  on  any  part  of  the  palmar  surface 
of  the  hand  or  fingers  or  the  soles  of  the  feet.  Though  not  absolutely 
diagnostic,  a  unilateral  character  of  the  lesion  is  somewhat  more 
frequent  in  tertiary  and  hereditary  syphilis. 

The  diagnosis  rests  on  the  sharp  limitation  of  the  spots;  on~ 
their  margin  of  hyperkeratosis  with  a  central  depression;  on  the 


21S 


KERATOSES 


infiltration  of  the  base,  which  is  of  greai  value  when  demonstrable; 
finally,  on  the  slight  tendency  of  the  lesions  to  encroach  upon 
the  neighboring  regions.  It  goes  without  saying  that  the  ante- 
cedents, the  co-existence  of  other  symptoms  of  syphilis,  and  the 
Wassermann  reaction  must  be  taken  into  consideration. 


i  it.     Late  palmar  syphilide. 


These  syphilides  are  often  obstinate  and  recurrent.  Treatment 
with  calomel  injections,  or  preferably  arsphenamin,  often  accom- 
plishes their  rapid  removal,  while  all  other  less  forcible  measures 
generally  fail.  Local  treatment,  with  mercurial  or  with  salicylic 
acid  plaster  may  serve  as  a  useful  adjuvant. 

Moreover,  in  all  keratodermas,  one  must  never  neglect  to  soften 
and  remove  the  horny  layer  (by  means  of  moist  dressings,  inunction 
with  potash  soap,  or  salicylic  acid  preparations),  in  order  to  open 
the  way  for  or  otherwise  assist  the  special  medication  that  is 
indicated. 

KERATOSIS  OF  MUCOUS  MEMBRANES. 

The  mucosa  of  the  buccal  cavity  and  the  genital  organs  possess, 
like  the  skin,  a  papillary  body  and  a  Malpighian  layer,  but  the 


Keratosis  of  mucous  membranes  219 

granular  layer  is  absent  in  the  latter  and  the  keratinization  of  the 
superficial  layers  is  incomplete. 

The  lining  of  the  red  border  of  the  lips,  that  of  the  prepuce  and 
glans,  as  well  as  that  of  a  large  portion  of  the  vulva,  has  a  structure 
related  to  that  of  the  epidermis,  so  that  these  surfaces  are  called 
semi-mucosse. 

Under  pathological  conditions,  these  mucosae  and  semi-mucosse 
may  become  the  seat  of  white  spots  or  patches  due  to  the  appear- 
ance in  their  epithelium  of  a  great  abundance  of  keratohyalin  and 
eleidin  and  a  genuine  keratinization.  The  term  of  keratosis  is  justi- 
fied in  these  cases. 

Leukoplakia. — This  affection,  which  is  also  known  as  leukokera- 
tosis,  white  spots  of  smokers — and  erroneously  called  buccal 
psoriasis,  tylosis  lingua,  buccal  ichthyosis,  etc. — is  the  most  common 
form  of  keratosis  of  mucous  membranes. 

Symptoms. — Leukoplakia  is  almost  invariably  located  in  the  mouth, 
exceptionally  in  the  genital  regions.  In  the  mouth,  it  is  usually  the 
tongue,  on  its  anterior  half,  which  is  involved  to  the  highest  degree. 
In  some  cases,  the  lesions  predominate  on  the  lateral  portions  of  the 
back  of  the  tongue,  in  others  on  the  margins  or  the  middle;  or  again, 
the  upper  surface  of  the  organ  is  affected  as  a  whole;  the  lower 
surface  is  less  commonly  invaded. 

More  frequent,  but  as  a  rule  not  so  marked,  is  a  localization  of 
the  disease  on  the  internal  aspect  of  the  cheeks,  in  the  form  of  a 
symmetrically  arranged  triangle;  representing  the  commissural 
white  spots  of  smokers.  The  posterior  region  of  the  cheeks,  the 
gums  and  the  palate,  are  not  often  attacked  by  leukoplakia,  which 
is  altogether  exceptional  in  the  pharynx  and  larynx. 

On  the  lips,  leukoplakia  occupies  the  posterior  surface,  the  free 
margin,  the  external  red  surface,  sometimes  the  commissures,  or  all 
these  regions  as  a  whole. 

In  women,  leukoplakia  may  be  observed  on  the  vulva,  notably 
on  the  inner  surface  of  the  labia  majora,  on  the  labia  minora,  the 
prepuce,  the  clitoris,  the  vestibule,  sometimes  in  the  vagina  and 
around  the  anus.  In  men,  leukoplakia  of  the  prepuce  and  glans 
is  rather  rare. 

The  lesions  begin  with  a  smooth  condition  of  the  mucosa,  which 
is  reddened  or  of  an  opaline  hue.  Once  established,  they  assume 
two  different  aspects,  according  to  the  severity  of  the  case. 

Mild  leukoplakia  is  characterized  by  obliteration  of  the  papillae 
and  the  grooves  of  the  mucosa,  which  shows  a  whitish,  grayish, 
bluish  or  white  color,  indicative  of  a  change  in  the  transparency  of 
the  epithelium.  Exceptionally  large  pinkish  papillae  may  be  seen 
shining  through  this  smooth  whitish  veneer. 

The  lesions  are  arranged  in  spots  or  patches  of  extremely  variable 


220  KERATOSES 

dimensions,  irregular  configuration,  sinuous,  festooned  or  ragged 
margins,  sometimes  sharply  outlined,  sometimes  gradually  fading 
into  the  normal  state.  The  entire  leukoplasic  surface  may  present  a 
uniform  appearance  or  the  center  may  be  more  opaque  and  thick- 
ened.  The  confluence  of  these  spots  gives  rise  to  patches,  unevenly 
checkered  in  dark  red,  gray  or  white.  The  keratotic  layer,  which 
is  always  very  adherent,  cannot  be  removed  by  scraping,  without 
exposing  the  submucosa;  but  it  is  apt  to  desquamate  in  small  opaline 
shreds,  which  on  the  lips,  for  instance,  the  patient  can  pull  off  with 
his  teeth. 

The  severe  or  marked  form  of  leukoplakia  is  connected  by  inter- 
mediate stages  with  the  mild  type.  The  thickening  of  the  mucosa 
and  of  its  horny  coat  may  become  considerable.  Either  on  an 
already  leukoplasic  surface,  or  on  a  healthy  basis,  hard,  inelastic, 
pearly  or  snow-white  patches  make  their  appearance,  several  centi- 
meters thick  with  gently  sloping  or  steep  borders,  with  a  smooth  or 
roughened  surface,  closely  adherent  to  the  underlying  tissues.  They 
may  become  detached  spontaneously,  at  intervals  of  months  or 
years,  but  are  promptly  reproduced.  The  entire  tongue  is  sometimes 
held  in  a  cracked  "cardboard"  leukoplasic  case.  The  cheeks,  the 
vulva,  or  the  glans  penis  may  also  be  covered  with  a  coat  of  this  kind. 

The  keratotic  patches  are  often  furrowed  by  folds  or  fissures; 
more  rarely,  they  are  studded  with  acuminated  horny  protuberances. 
This  verrucous  variety  is  especially  noteworthy  as  being  frequently 
the  prelude  to  epitheliomatous  changes. 

Another  complication  of  leukoplakia,  inconvenient  and  trouble- 
some rather  than  actually  serious,  is  an  obstinate  ulceration  which 
I  have  named  leukoplasic  ulcer  and  which  will  be  discussed  else- 
where in  this  book  (p.  307). 

The  condition  of  the  mucosa  underlying  the  leukoplakia  is  difficult 
to  determine.  In  the  case  of  the  tongue,  it  is  as  a  rule  sclerotic  and 
even  retracted  proportionately  to  the  hyperkeratosis,  either  super- 
ficially or  deeply,  as  a  result  of  the  syphilitic  sclerotic  glossitis  which 
i^  the  ordinary  substratum  of  the  severe  leukoplakias.  Elsewhere 
it  is  often  in  a  more  or  less  marked  state  of  atrophic  sclerosis. 

The  subjective  sensations — which  are  absent  in  the  mild  forms  of 
the  disease — consist  of  an  impairment  of  mobility  and  an  unpleas- 
ant sensation  of  dryness  and  hardness  in  the  severe  cases;  acute 
tenderness  and  shooting  pains  usually  appears  only  as  the  result  of 
fissures. 

Vulvar  Leukoplakia  carefully  studied  by  Jayle  and  Bender — 
does  not  differ  from  the  same  disease  as  seen  in  the  mouth.  It  may 
affect  the  vaginal  mucosa  and  very  rarely  the  uterine  cervix.  It 
may  precede  or  accompany  kraurosis  or  sclerotic  atrophy  of  the 
vulva,  with  which  it  has  been  confused. 


KERATOSIS  OF  MUCOUS  MEMBRANES  221 

The  course  of  leukoplakia  is  altogether  irregular.  It  usually  pro- 
gresses slowly  and  persists  throughout  life.  It  may  remain  entirely 
stationary  under  the  influence  of  proper  hygiene,  or  it  may  even 
subside  and  disappear,  at  least  partially;  but  it  is  very  prone  to 
recurrence. 

Leukoplakia  and  Cancer. — The  gravity  of  leukoplakia  is  due  to  its 
complications,  which  are  frequent  and  very  dangerous.  Fissures, 
cracks  and  erosions  are  very  common  in  the  vicinity  of  carious 
teeth  or  as  the  result  of  faulty  hygiene;  they  give  rise  to  acute  radia- 
ting pains  and  may  lead  to  lymphangitis  or  to  suppuration. 


Fig.  71. — Cancer  (lobulated  epithelioma)  on  leukoplakia  of  the  tongue. 

Epithelioma,  however,  constitutes  the  real  danger  of  leukoplakia. 
It  may  supervene  in  all  the  forms,  especially  the  most  severe  types, 
and  at  any  stage  of  the  leukoplakia.  Its  relative  frequency  has  been 
variably  estimated  at  30  and  even  above  50  per  cent,  of  the  cases; 
a  ratio  of  15  to  20  per  cent,  seems  to  me  nearer  the  truth.  [This 
estimate  which  seems  to  me  very  high  applies,  of  course,  only  to 
the  severe  cases.]  The  physician  may  save  his  patient  from  an 
awful  death,  such  as  supervenes  in  cancer  of  the  tongue,  if  he 
manages  to  discover  in  time  the  incipient  complication  and  is 
sufficiently  energetic  and  convincing  to  obtain  consent  to  a  timely 
operation. 


222  KERATOSES 

Cancer  of  the  tongue  on  a  basis  of  leukoplakia  (Fig.  71)  is  almost 
invariably  of  the  lobulated  or  spinocellulare  type  and  of  the  variety 
which  I  call  cancroid:  exceptionally,  it  is  of  the  tubular  type.  It 
has  two  principal  modes  of  onset. 

In  most  cases  it  begins  with  a  circumscribed,  lenticular  or  more 
extensive  papillomatous  elevation,  often  encircled  by  a  keratotic 
margin,  with  a  very  slightly  indurated  base;  under  this  superficial 
form  it  spreads  on  the  surface  during  a  few  weeks,  a  month  or  two, 
before  invading  the  depths  of  the  tissues,  so  that  prompt  operative 
interference  is  not  infrequently  successful. 

More  rarely  the  epithelioma  develops  deeply  from  the  start, 
originating  from  a  fissure  which  has  persisted  one  or  two  weeks  and 
at  whose  level  palpation  reveals  a  minute  circumscribed  woody 
induration.  In  these  cases,  surgical  intervention  can  hardly  come  in 
time.    Leukoplasic  ulcers  only  exceptionally  give  rise  to  cancer. 

On  the  lips,  cheeks  and  genitals,  epithelioma  appears  under 
entirely  similar  conditions. 

I  have  emphasized  for  many  years  the  line  of  conduct  to  be  fol- 
lowed when  cancer  is  suspected  in  the  course  of  a  leukoplakia;  and 
increasing  experience  causes  me  to  be  more  and  more  positive  in  this 
respect. 

What  should  not  be  done,  is:  ( 1 )  to  wait  until  the  symptoms  become 
more  pronounced,  the  epithelioma  develops  and  the  glands  become 
enlarged;  (2)  to  resort  to  an  antisyphilitic  "therapeutic  test"  which 
causes  the  loss  of  valuable  time;  (3)  to  irritate  the  suspicious  lesion 
with  cauterization  of  any  kind,  diathermia,  etc.;  (4)  finally,  to  try 
radiotherapy  or  radium,  which  are  inefficient  or  even  harmful  in 
these  cases. 

What  .should  be  done:  in  all  cases  where  the  diagnosis  is  not  abso- 
lutely certain,  a  specimen  removed  from  the  living  subject  should 
be  at  once  examined  under  the  microscope,  a  step  which  will  provide 
a  definite  answer  in  less  than  twenty-four  hours;  or,  when  cancer  is 
known  to  exist,  to  proceed  at  once  and  without  delay  to  the  surgical 
extirpation  of  the  lesion,  which  affords  the  only  prospect  of  salvation. 
[The  rich  lymphatic  tissue  of  the  tongue  increases  the  risk  of  dis- 
semination as  a  consequence  of  the  manipulations  inseparable  from 
biopsy.  After  biopsy,  therefore,  a  delay  of  even  twenty-four  hours 
may  have  serious  consequences.  In  my  opinion,  the  complete 
operation,  whenever  possible,  should  follow  immediately  on  the  estab- 
lishment of  the  diagnosis  which  should  therefore  be  made  on  frozen 
sections,  with  due  consideration  of  the  difficulties  of  this  method.] 

Pathological  Anatomy.  On  a  leukoplasic  mucosa  (  Fig.  72)  the  rete 
Malpighii  is  greatly  thickened  (acanthosis)  and  its  interpapillary 
plugs  are  hypertrophied  in  all  directions;  between  the  mucous  body 
and  the  extremely  thick  horny  layer  which  covers  it,  and  which 


KERATOSIS  OF  MUCOUS  MEMBRANES  223 

consists  of  cells  deprived  of  their  nuclei,  a  granular  layer  has  made 
its  appearance,  with  very  abundant  keratohyaline  and  eleidin, 
diffusing  into  the  stratum  corneum;  these  lesions  explain  the  white- 
ness of  the  patches. 

In  the  papillary  body  of  the  corium  is  seen  a  variable  infiltration  of 
round  cells  around  the  vessels,  as  well  as  sometimes  the  lesions  of 
endo-peri vasculitis  and  connective-tissue  sclerosis. 


B 

1 

c 

A                                                                             ' 

i 

I         .                                                                              ,.■+       /    1  j       .     \\ 

^«^-,3:/. /■'•'  ■  w"'V-;--.v^.^-v.-=: ■'"'           ^       \J      \    / 

•  /     .  .   ■:.    ;.              mm 

:  '    i                             :                                    .;  : 

Fig.  72. — Simple  and  verrucous  leukoplakia  of  the  tongue.  Under  the  epithe- 
lium, which  is  greatly  thickened  and  abundantly  provided  with  keratohyalin  and 
diffuse  eleidin,  is  seen  an  inflammatory  cellular  infiltrate,  especially  abundant  at 
the  level  of  the  verrucous  portion;  a  newly  formed  layer  of  sclerotic  tissue,  traversed 
by  numerous  dilated  bloodvessels,  has  become  interposed  between  the  epithelium  and 
the  muscular  tissue.  No  trace  of  epitheliomatous  change  is  demonstrable.  A,  simple 
leukoplakia;  B,  eleidin;  C,  verrucous  leukoplakia;  D,  muscular  tissue;  E,  sclerosis; 
F,  inflammation.      X  18. 

When  epitheliomatous  transformation  occurs,  it  results  from 
atypical  budding  of  the  interpapillary  processes  or  of  the  epithelium 
which  lines  the  fissures  (Fig.  192).  Invasion  of  the  lymph  spaces 
takes  place  very  rapidly,  especially  in  the  tongue. 

Etiology. — Leukoplakia  is  at  least  ten  times  more  frequent  in 
men  than  in  women.  It  is  observed  especially  from  thirty  to  fifty 
years  of  age,  but  cases  have  been  reported  at  the  age  of  twelve  years 
(Benard)  or  even  younger.  I  have  encountered  it,  complicated  by 
cancer  of  the  tongue,  in  a  girl  of  nineteen  years,  which  is  excep- 


224  KERATOSES 

tional  from  every  point  of  view.  Leukoplakia  may  result  from  multi- 
ple causes  of  different  kinds.     The  equation: 

Leukoplakia  =  syphilis  +  tobacco 

although  often  true,  is  certainly  too  absolute.  Tobacco  is  the  most 
powerful  of  the  local  causes;  but  dental  lesions,  false  teeth,  abuse 
of  alcohol  and  condiments,  etc.,  also  play  a  part  in  the  production 
of  buccal  leukoplakia,  especially  in  non-smokers  and  in  women. 
Other  irritants  intervene  in  genital  and  anal  leukoplakia. 

In  the  great  majority  of  the  cases,  leukoplakia  develops  on  a 
syphilitic  soil,  but  I  believe  that,  even  on  the  plea  of  hereditary 
syphilis,  it  is  not  justified  to  consider  it  as  an  invariably  para- 
syphilitic  affection,  as  maintained  by  Professors  Landouzy  and 
Gaucher.  There  are  cases  where  syphilis  is  absent,  where  the 
Wassermann  reaction  is  negative  and  where  nothing  can  be  sus- 
pected except  local  irritative  factors,  obscure  auto-intoxications,  or 
perhaps  an  individual  predisposition. 

At  the  present  state  of  our  knowledge  it  is  impossible  to  say  if 
it  is  correct  to  recognize  a  syphilitic  leukoplakia,  and  other  nicotine, 
dental,  post-infectious  leukoplakias,  differing  by  their  symptoms 
and  their  course,  or  if  leukoplakia  is  a  syndrome  resulting  from 
various  causes,  a  modification  of  the  epithelial  evolution  resulting 
from  infectious  or  toxic  vascular  lesions.  The  last-named  theory 
is  the  most  probable  in  my  opinion. 

Treatment. — This  must  be  carefully  handled  and  requires  in  the 
first  place  a  strict  buccal  hygiene:  absolute  abstinence  especially 
from  tobacco,  from  alcohol,  condiments  and  highly  spiced  foods, 
irritative  mouth-washes;  the  teeth  must  be  put  and  kept  in  perfect 
condition. 

Soothing  or  weakly  alkaline  irrigations  of  the  mouth  with  Vichy 
water,  or  Saint  Christau  water,  are  useful  palliatives,  preferable  to 
pastils  and  compressed  tablets.  The  warm  mineral  springs  of 
Sainl  Christau,  with  local  spraying,  or  to  a  less  degree,  various 
sulphur  springs,  yield  favorable  results. 

Among  topical  applications,  those  most  to  be  recommended  are 
glycerol  salves  or  ointments  made  with  balsam  of  Peru,  oil  of  cade, 
oil  of  birch,  or  salicylic  acid.  In  case  of  thick  keratotic  patches, 
their  detachment  may  be  furthered  by  painting  with  acid  nitrate  of 
mercury,  chromic  acid,  or  potassium  bichromate,  etc.  Sometimes, 
the  destruction  of  certain  patches  with  the  thermocautery,  or  their 
surgical  removal,  may  be  called  for.  In  a  general  way,  however, 
caustics  arc  not  /<>  he  trusted,  especially  in  case  of  fissures,  which 
patients  like  to  treat  and  abuse  with  silver  nitrate;  cauterizations 
are  certainly  more  injurious  than  useful.    Radiotherapy  and  radium, 


KERATOSIS  OF  MUCOUS  MEMBRANES  225 

energetically  employed,  have  a  few  cures  to  their  credit,  but  on  the 
other  hand  a  large  number  of  failures  are  on  record. 

The  operative  indications  in  case  of  probable  or  certain  cancer 
need  not  be  repeated  here. 

General  treatment  with  antisyphilitic  agents,  is  evidently  required 
in  the  presence  of  specific  antecedents  or  a  positive  Wassermann 
reaction;  but  it  has  been  found  effective  even  in  cases  where 
syphilis  was  apparently  excluded.  Intragluteal  calomel  injections 
exert  such  a  preponderating  action  in  leukoplakia  that  they  were 
accorded  the  preference  until  the  introduction  of  arsenobenzol ; 
the  latter  is  still  more  active,  especially  in  combination  with 
soluble  mercurial  injections.  In  obstinate  cases,  I  have  often 
been  excellently  served  by  local  treatment  with  injections  of  very 
dilute  cyanide  of  mercury.  Iodides  are  not  to  be  recommended. 
When  an  established  leukoplakia  in  a  syphilitic  patient  has  only 
partially  yielded  to  specific  treatment,  or  resisted  it,  the  advantage 
will  at  least  have  been  served  of  opposing  the  extension  of  the  dis- 
ease and  preventing  the  appearance  of  other  syphilitic  manifestations. 

General  hygienic  recommendations  must  not  be  neglected, 
especially  in  regard  to  diet,  correcting  dyspepsia  if  necessary,  or 
controlling  any  auto-intoxications  which  may  have  been  discovered. 

There  is  a  certain  class  of  leukoplasic  patients  whose  life  is  made 
miserable  by  a  regular  "cancerophobia,"  liable  to  be  maintained 
by  treatment  of  any  kind.  In  these  cases,  a  judicious  psychotherapy 
is  indicated. 

Syphilitic  Glossitis. — It  seems  to  me  useful  to  describe  in  connec- 
tion with  leukoplakia  the  lesions  which  secondary  and  tertiary 
syphilis  so  frequently  produce  upon  the  tongue.  This  organ  may 
present : 

1.  The  smooth  patches  of  Fournier;  "mowed-lawn  patches"  of 
Cornil.  These  are  pinkish  spots,  devoid  of  papillse,  dry,  non-indur- 
ated, round  or  oval,  distinctly  outlined,  though  without  special 
border.  These  lesions  may  be  premature,  developing  rather  rapidly, 
or  delayed,  and  in  this  case  are  much  more  obstinate. 

2.  Opaline  mucous  patches  seen  only  on  the  margins  or  at  the  tip 
of  the  tongue,  generally  near  carious  teeth;  sometimes  they  are 
eroded  or  fissured;  rarely,  on  the  back  of  the  tongue,  they  are 
papular  or  lozenge-shaped. 

3.  Hypertrophic  or  papillomatous  papules,  with  a  gray  or  reddish 
surface,  very  rare,  occupying  the  vicinity  of  the  circumvallate 
papilla?  where  they  become  confluent  in  a  large  patch;  from  here 
they  reach  the  back  of  the  tongue,  which  then  assumes  the  appear- 
ance called  "toads'  back." 

4.  Tuber  culo-ulcerative  syphilides  and  gummas,  which  will  be  dis- 
cussed elsewhere;  these  may  leave  sclerotic  cicatrices. 

15 


22ii 


KERATOSES 


5.  Finally,  sch  n  tic  glossitis,  of  the  tertiary  period,  very  common, 
especially  in  men;  it  may  be  superficial  or  deep. 

In  the  superficial  form  there  are  a  few  islands  of  cortical  sclerosis, 
or  a  single  smooth  red  surface,  with  lamellar  induration,  sometimes 
complicated  by  fissures. 

Dei  "p  glossitis,  occupying  especially  the  middle  or  the  borders  of 
the  tongue,  or  its  entire  anterior  half,  is  characterized  by  an 
irregular  lobulation,  prominent  papillae  being  separated  by  deep 
grooves  united  in  a  network:  fibrous  induration  of  the  organ  is  also 
demonstrable  Fig.  73).  'Die  mucosa  is  wine-red  in  some  places, 
discolored  in  other-,  smooth,  tense,  practically  devoid  of  papilla? 
throughout. 


Fig.  7'.',. — Sclerot 


ijred 


ssitis  of  the  deep  variety,  in  a  woman 
ixty  years. 


The  coexistence  of  syphilitic  lingual  sclerosis  and  leukoplakia  is 
very  common. 

Sulcated  or  Scrotal  Tongue.  Sclerotic  glossitis  must  not  be  con- 
fused with  ;t  congenital,  often  familial,  malformation  which  bears 
this  name.  The  organ  in  such  cases  is  lobulated  and  fissured;  its 
very  villous  surface  is  studded  with  prominent  fungiform  papillae. 
But  its  consistence  is  soft,  there  is  no  pain  and  the  condition  is 
absolutely  permanent. 

Median  Rhomboidal  Glossitis.  -This  affection  was  described  in 
January  of  1914  by  Brocq  and  Pautrier;  it  is  not  rare  and  I  have 
seen  numerous  instances.    The  dorsal  asped  of  the  tongue,  in  front 


KERATOSIS  OF  MUCOUS  MEMBRANES  227 

of  the  circum vallate  papillae  presents  a  reddish  raw  surface;  the 
lesion  is  usually  mammillated,  slightly  indurated,  indolent,  and 
extremely  persistent.  Anatomically,  nothing  is  found  but  hyper- 
acanthosis  and  a  moderate  infiltration  of  the  corium.  This  glossitis, 
which  occurs  especially  in  adults,  is  often  wrongfully  ascribed  to 
syphilis;  its  nature  is  unknown;  it  resists  all  local  or  general  treat- 
ment. 

Lichen  Planus  of  Mucous  Membranes. — This  is  very  commonly 
confused  with  leukoplakia  or  with  syphilides.  Its  diagnosis  never- 
theless is  relatively  easy. 

Lichen  planus  of  the^mucosse,  especially  of  the  mouth,  is  not  rare. 
It  is  observed  in  about  one-half  of  all  lichen  cases.  It  may  persist 
beyond  the  cure  of  the  cutaneous  manifestations,  or  it  may  consti- 
tute a  primary  and  sometimes  exclusive  localization.  Familiarity 
with  its  characteristics  is  therefore  necessary. 


Fig.  74. — Lichen  planus  of  the  tongue  in  a  man  aged  forty-two  years. 


The  seat  of  election  of  lichen  planus  of  the  mucosae  is  in  the  first 
place  on  the  internal  aspect  of  the  cheeks,  at  the  level  of  the  alveolar 
margin,  preferably  opposite  the  last  molars.  It  manifests  itself  on 
one  side,  or  symmetrically,  in  form  of  one  or  several  white  patches 
with  an  irregular  reticular  or  annular  arrangement  resembling  lace- 
work,  pure  white  or  bluish  in  color,  on  a  normal  background;  the 
more  or  less  delicate  network  is  crossed  by  larger  bars.  Erosion 
or  desquamation  never  occurs. 

Next  in  order  is  the  localization  on  the  tongue  (Fig.  74),  which 
may  present  either  patches  of  a  dull  bluish  white,  smaller  than  a 
lentil,  with  a  reticular  or  fern-leaf  design,  or  opaline  surfaces 
through  which  a  few  rose  colored  papillae  project. 


228  KERATOSES 

Lichen  planus  may  furthermore  be  met  with  on  the  lips,  palate, 

gums,  tonsils,  on  the  glans  and  prepuce,  where  it  is  often  annular,  etc. 

These  lesions  are  absolutely  sluggish  and  indolent;  they  persist 

for  months,  or  oftener  for  many  years,  undergoing  very  gradual 

changes. 

Histology  shows  a  thickening  of  the  epidermis  in  all  its  layers, 
the  appearance  of  a  stratum  granulosum,  dome-shaped  papilhe, 
and  a  cellular  infiltration  in  the  papillary  body.  The  structure  is 
accordingly  entirely  that  of  lichen  planus  of  the  skin.  The  explana- 
tion of  the  white  color  i>  the  same  as  for  the  network  of  the  cutaneous 
papules  of  typical  lichen  planus;  it  moreover  assumes  an  identical 
form  in  the  majority  of  cases. 

The  treatment  of  lichen  of  the  mucosae  need  not  be  very  active, 
the  condition  being  obstinate  but  by  no  means  serious.  It  never 
leads  to  cancer.  Soothing  mouth  washes,  inunction  with  balsam  of 
Peru,  painting  with  potassium  permanganate,  1  to  100,  are  quite 
sufficient.  High  frequency  currents  and  radium  therapy  have  not 
yielded  favorable  results  in  my  experience.  A  bland  diet,  good 
hygiene,  a  quiet  life,  arsenic  internally,  are  recommended. 

Lupus  Erythematodes. — It  is  exceptional  for  lupus  erythematodes 
to  affect  the  mucous  membranes.  It  is  sometimes  seen  to  radiate 
in  the  form  of  a  scaly  redness  on  the  posterior  aspect  of  the  lower 
lip  starting  from  the  free  border.  When  it  develops  on  the  internal 
aspect  of  the  cheeks  or  on  the  tongue,  it  manifests  itself  in  the  form 
of  a  circumscribed  patch,  mottled  with  white  and  bright  red,  and 
partly  atrophic. 

Smooth  Patches  of  the  Tongue.— Occasionally,  the  tongue  is  seen 
to  present  >pot>  or  large  patches  devoid  of  papilhe,  reddish  and 
glistening,  without  a  white  margin,  absolutely  stationary  during 
months  or  years.  They  are  entirely  indolent  and  the  patient  may 
be  unaware  of  their  existence.  In  other  cases,  they  are  very  sensitive, 
and  associated  with  ghssodyniu. 

These  patches  arc  always  suggestive  of  the  cropped  patches  of 
sj  philis,  or  of  incipient  leukoplakia.  I  am  personally  convinced  that 
they  may  be  referable  to  a  variety  of  causes,  notably  tuberculosis, 
diabetes,  chronic  dyspepsias,  severe  neuropathies;  sometimes  they 
are  connected  with  carious  teeth  or  badly  fitting  artificial  dentures. 
Those  cases  in  which  desquamation  and  a  varnished  appearance 
are  extensively  combined,  or  involve  almost  the  entire  tongue,  are 
known  under  the  name  of  red  tongue,  or  glossitis  of  nervous  arthritics. 
Glossitis  Exfoliativa  Marginata. — This  peculiar  affection  which 
also  bears  the  names  of  exfoliatio  areata,  or  geographical  tongue, 
gives  rise  to  circinate  patches,  rings  and  other  designs  upon  the 
tongue.  The  spots  are  composed  of  a  white  border,  one  or  two 
millimeters  wide,  within  which  lies  a  desquamated  surface,  bright 


KERATOSIS  OF  MUCOUS  MEMBRANES  229 

red  near  the  margin,  gradually  fading  away  at  a  distance  from  it. 
More  or  less  rounded  at  first,  the  spots  spread  rapidly  and  become 
confluent  with  their  neighbors ;  the  resulting  design  may  thus  become 
entirely  altered  in  a  day  or  two.  New  spots  are  incessantly  repro- 
duced.   There  is  no  induration  of  the  mucosa. 

Entirely  indolent,  usually  ignored  by  the  bearer,  this  affection 
lasts  for  years  or  indefinitely.  Its  etiology  is  unknown.  It  is 
observed  in  children  and  in  adults.  It  is  often  familial.  Sulcated 
tongues  are  specially  predisposed  to  it.  In  spite  of  the  parasitical 
appearance  of  the  lesions,  no  case  of  contagion  has  been  reported. 
Confusion  must  be  guarded  against,  especially  with  syphilitic  lesions. 
Parrot  referred  exfoliative  glossitis  to  congenital  syphilis,  which  is 
certainly  incorrect. 

[Chronic  superficial  excoriation  of  the  tongue,  or  Mceller's  glossitis, 
is  characterized  by  irregular  circumscribed  intensely  red  spots  of 
great  chronicity,  without  tendency  to  extension  or  ulceration,  located 
in  the  middle  or  the  anterior  portion  of  the  tongue.  Contact  with 
food  usually  provokes  severe  burning  or  lancinating  pain.] 

Black  (Villous)  Tongue. — This  is  a  lingual  keratosis,  in  which  the 
filiform  papillae,  far  from  becoming  obliterated,  as  in  leukoplakia,  be- 
came immediately  elongated  and  assume  a  dark,  black  or  brown  color. 

The  affection  begins  on  the  middle  line,  not  far  from  the  circum- 
vallate  papillae  and  spreads  forward  and  to  the  sides,  remaining 
more  pronounced  at  its  point  of  origin;  the  borders  of  the  lesion  are 
diffuse.  The  papillae,  which  may  reach  the  length  of  a  centimeter, 
lie  like  mown  wheat  and  a  parting  may  be  made  as  in  the  hair 
(black  hairy  tongue).  The  brown  color  is  darker  at  the  extremity  of 
the  papillae. 

When  these  papillae  are  excised,  the  microscope  shows  an  enor- 
mous hypertrophy  of  their  corneal  sheath,  the  lamellae  of  which 
adhere  to  the  axis  and  spread  away  from  it  like  the  branches  of  an 
old  pine  tree.  The  presence  of  eleidin  has  been  reported  at  the 
border  of  the  rete.  The  black  color  is  due,  not  to  foreign  bodies 
or  to  pigment,  but  to  a  smoky  tinge  of  the  horny  substance  itself, 
as  in  black  ichthyosis. 

This  rather  uncommon  affection  is  observed  in  adults  and  aged 
individuals;  I  have  seen  it  associated  with  pharyngo-mycosis .  It 
proceeds  in  attacks,  followed  by  partial  desquamations;  it  is 
sometimes  prolonged  for  months  or  years  and  has  a  tendency  to 
recurrence. 

Black  tongue  is  neither  contagious  nor  inoculable.  It  has  been 
suspected  of  being  due  to  a  special  infection  by  a  microbe  or  a  yeast. 
But  the  results  of  investigations  which  have  been  undertaken  to 
prove  this  are  entirely  contradictory  and  the  parasitical  theory  can 
no  longer  be  maintained  (Lebar,  1917). 


230 


KERATOSES 


There  arc  cases  of  villous  tongue,  presenting  identical  features, 
but  without  a  brown  or  black  coloration. 

This  affection  must  not  be  confused  with  a  simple  coated  tongue, 
with  an  accidental  discoloration  due  to  articles  of  food  or  medicinal 
agents,  with  the  pigmentation  of  Addison's  disease  or  that  of 
argyria.  Mouth  washes  with  peroxide  water  sometimes  produce 
at  the  end  of  a  certain  time  an  appearance  identical  with  that  of 
villous  black  tongue;  but  the  surface  promptly  returns  to  the  normal 
when  these  washes  are  omitted.  In  several  great  dystrophies,  such 
as  acanthosis  nigricans  and  psorospermosis,  the  tongue  is  villous 
in  its  entire  extent,  but  of  a  normal  or  whitish  hue. 

The  treatment  consists  of  alkaline  mouth  washes  and  painting  with 
a  5  per  cent,  or  10  per  cent,  alcoholic  solution  of  salicylic  acid. 

DYSKERATOSES. 

The  dermatoses  which  I  group  under  this  heading  are  charac- 
terized by  a  faulty  development  of  the  epidermis,  in  the  course  of 
which  a  certain  number  of  Malpighian  cells  become  differentiated 
from  their  fellows,  undergoing  an  abnormal,  premature  and  imper- 
fect keratinization.  These  dyskeratotic  cells  are  present  in  the 
layers  of  the  epidermis,  as  far  as  in  the  horny  layer,  in  the  form  of 


FlG.  75. — Round  bodies  and  granules  of  follicular  psorospermosis.  a  and  h 
round  bodies,  Malpighian  cells  surrounded  by  a  membrane  and  containing  granula- 
tions of  keratohyalin  and  a  nucleus;  c  and  d,  granules,  nucleated  dyskeratotic  cells 
which  have  completed  their  development. 


"round  bodies,"  "granules"  (Fig.  75),  globes  or  corpuscles,  with 
or  without  nuclei,  easily  distinguished  from  the  still  normal  cells  as 
well  as  from  the  parakeratotic  cells. 

The  group  of  dyskeratoses  comprises:  (1)  The  disease  which  I 
had  named  psorospermosis  follicularis  vegetans;  (2)  Paget's  disease 
of  the  nipple;  (3)  the  precancerous  dermatosis  of  Bowen,  or  lenticular 
and  disco  id  a  I  dyskeratosis. 

From  the  strict  viewpoint  of  the  histological  structure,  moUuscum 
contagiosum   should  likewise  be  classified  with  the  dyskeratoses; 


DYSKERATOSES  231 

but  this  affection  is  altogether  different  from  the  preceding  and 
will  be  discussed  with  the  benign  tumors. 

Dyskeratosis  and  analogous  cellular  changes  are  also  observed 
in  several  forms  of  cancer,  notably  in  the  majority  of  spinocellular 
epitheliomas,  where  they  were  formerly  described  under  the  name 
of  physalides  (Virchow)  and  more  recently  under  that  of  pseudo- 
coccidias;  and  two  dyskeratoses,  Paget's  disease  and  Bowen's,  take 
first  rank  among  the  precancerous  affections.  This  fact  is  interest- 
ing and  suggestive,  but  its  significance  is  not  clear  as  long  as  the 
cause  and  nature  of  dyskeratosis  remain  unknown. 

Darier's  Disease. — This  important  dermatosis  which  I  described 
in  1889  under  the  name  of  psorospermosis  follicular  is  vegetans,  is  gen- 
erally called  Darier's  disease,  especially  abroad;  the  most  appropriate 
denomination  for  it,  in  my  opinion,  would  be  dyskeratosis  follicularis.1 

It  manifests  itself  clinically  as  papulo-crusts,  often  follicular, 
capable  of  becoming  confluent  in  verrucous  surfaces  with  crumbly 
margins,  located  symmetrically  in  certain  definite  regions.  It  is 
essentially  chronic  and  almost  incurable. 

The  improper  name  of  psorospermosis  which  I  had  attributed  to 
it,  was  based  on  an  erroneous  interpretation  of  the  corpuscles  which 
are  found  in  the  epidermis  and  which  at  the  time  were  mistaken 
for  coccidia  or  psorospermia,  namely  for  parasites  of  the  sporozoa 
group.  They  have  now  been  shown  to  be  really  dyskeratotic  epi- 
dermic cells. 

The  etiology  of  this  dermatosis  is  unknown,  it  has  been  observed 
in  all  countries,  but  is  relatively  rare;  it  seems  to  affect  the 
male  sex  somewhat  more  frequently;  its  familial  and  hereditary 
character  is  apparent  from  numerous  observations,  but  there  is 
nothing  to  indicate  contagiousness.  It  has  been  compared  with 
ichthyosis,  the  icthyosiform  hyperkeratoses  and  acanthosis  nigricans; 
there  is  a  tendency  to  regard  it  as  a  dystrophy  of  the  epidermis  of 
congenital  origin. 

The  typical  eruptive  lesion  is  a  papule  covered  with  a  grayish 
brown  crust,  having  the  dimensions  of  a  pin-head  to  a  small  lentil. 
On  removal  of  the  hard  and  horny,  prominent  or  flattened,  rather 
adherent  crust,  it  is  found  to  be  imbedded  in  a  funnel-shaped  de- 
pression with  raised  margins,  into  which  it  sends  a  soft  yellowish 
process,  of  sebaceous  appearance;  this  depression  is  the  dilated 
orifice  of  a  pilo-sebaceous  follicle.  There  are  other  lesions,  however, 
which  are  not  follicular. 

At  the  onset  the  patients  notice  a  dirty  tinge  and  roughened 
state  of  the  skin;  later  on,  the  crusts  become  confluent  in  warty 
patches. 

1  In  the  original  this  section  is  headed  Psorospermosis,  etc.  The  editor  has 
substituted  the  name  by  which  the  disease  is  generally  known. — S.  P. 


232 


KERATOSES 


In  the  groins,  the  axilla'  and  in  all  moist  regions,  pinkish  globular 
or  crater-shaped  vegetations  may  develop,  in  exceptional  cases, 
arranged  in  cauliflower  or  fungoid  masses,  having  an  offensive  odor. 

The  eruption  is  symmetrical  and  occupies  large  areas.  Its  sites 
of  election  are:  the  face,  especially  the  temples  and  the  naso-labial 


-Follicular  dyskeratosis  [Darier's  disease];  gene 
dermatosis. 


distribution  of  the 


fold;  the  scalp,  which  becomes  crusted  and  moth-eaten,  but  without 
alopecia;  the  concha?  of  the  ears,  the  presternal  and  interscapular 
grooves;  the  belt  line,  the  perigenital  region  and  the  large  articular 
folds.  This  topographical  distribution  is  in  the  main  that  of 
seborrhea  (Fig.  76);  tlie  entire  trunk  and  the  external  aspect  of  the 


DYSKERATOSES 


233 


limbs  may  be  likewise  involved.  So-called  abortive  or  incomplete 
cases  are  not  very  uncommon. 

On  the  back  of  the  hands,  elevations  identical  with  flat  warts  are 
often  seen;  the  palmar  and  plantar  regions  present  a  punctate 
keratosis  composed  of  yellowish  translucid  points;  the  nails  are 
striated  and  brittle;  the  tongue  may  be  villous. 

The  disease  begins,  in  one-half  of  the  cases,  between  eight  and 
sixteen  years  of  age  (Fig.  77),  but  also  earlier  or  later;  sometimes 
at  the  temples  and  face,  sometimes  in  the  groins;  it  spreads  rapidly 
and  then  remains  indefinitely  stationary.  It  is  accompanied  by  no 
subjective  symptoms  and  interferes  in  no  way  with  the  general 
health. 


Fig.  77. — Follicular  dyskeratosis  [Darier's  disease]  in  a  girl  aged  eleven  years. 


The  pathological  anatomy  is  characteristic.  The  illustration 
(Fig.  78)  conveys  a  sufficient  idea  of  the  condition. 

The  microscopical  demonstration  of  the  granules  in  the  crusts 
which  are  easily  removed  from  the  patient,  and  of  the  round  bodies 
in  the  underlying  substance,  is  very  easy  and  suffices  for  a  positive 
confirmation  of  the  clinical  diagnosis. 


2:51  KERATOSES 

Without  curing  the  psorospermosis  entirely,  it  is  possible  to 
improve  the  patient's  condition  very  markedly  by  baths  and  soap 
washes,  inunctions  with  salves  containing  keratolyses,  followed  by 
reducing  agents  as  well  as  by  means  of  radiotherapy. 

Paget's  Disease  of  the  Nipple.  -This  is  a  chronic  affection  which 
develops  on  the  nipple  and  areola  of  women  past  forty  years  of  age; 
or,  exceptionally  in  men  in  the  perineoscrotal  and  some  other  regions. 
It  seemes  to  be  less  uncommon  in  England  and  in  the  United  States 
than  in  France. 


/* 


.   ■'  V:- 


; 


.  j** 


6 


Fig.  78. — Histology  of  follicular  dyskeratosis;  section  through  a  perifollicular 
papulo-cmst.  a,  orifice  of  a  hair-follicle ;  b,  b,  hairs,  and  c,  sebaceous  gland,  unchanged; 
d,  thickened  horny  layer  containing  (in  e  e)  collections  of  granules;  /,  /,  granular 
layer  interrupted  at  the  level  of  the  foci  of  dyskeratosis;  g,  g,  fissures  and  lacunae, 
resulting  from  fibrino-nmcous  disintegration  of  the  epidermis,  in  which  a  few  granules 
are  seen  Boating  {h,  h);  i,  i,  round  bodies. 

At  the  onset,  only  a  few  small  crusts  are  seen  on  the  nipple, 
with  warty  elevations  and  sometimes  a  serous  oozing.  After  some 
months  or  years,  a  progressively  extensive  erosion  makes  its  ap- 
pearance and  may  invade  the  entire  integument  of  the  breast.  At 
its  fully  developed  stage,  there  exists  an  eroded  or  ulcerated  red 
patch,  mottled  with  pinkish  epidermis-covered  islands,  remarkable 
for  its  distinctly  outlined  polycyclic  contours,  which  are  bordered 
by  a  narrow  margin  or  cuff  of  scales  (Fig.  79).    The  eroded  surface 


DYSKERATOSES  235 

presents  a  very  distinct  parchment-like  induration;  it  never  under- 
goes retrogression  or  spontaneous  cure.  The  nipple  is  retracted. 
The  lymph  glands  are  not  usually  enlarged.  Finally,  sometimes 
after  a  considerable  number  of  years,  a  malignant  neoplasm  may 
supervene  in  the  form  of  a  hard  superficial  or  deep  node  which  ulcer- 
ates and  presents  the  usual  appearance  of  cancer  of  the  lactiferous 
ducts,  or  of  ordinary  cancer  of  the  breast. 

The  differential  diag?wsis  from  eczema  of  the  mammary  areola, 
which  is  practically  limited  to  the  puerperium  or  to  cases  of  scabies 
(Fig.  157),  has  less  distinctly  circumscribed  borders  and  takes  an 
acute  course,  is  easy.  Certain  superficial  epitheliomas,  which  simu- 
late Paget's  disease,  can  be  differentiated  only  by  means  of  biopsy. 


Fig.  79. — Paget's  disease  of  the  nipple.     After  a  cast  in  the  Museum  of  the  St.  Louis 
Hospital,  Paris. 

The  histology  of  Paget's  disease  shows  a  Malpighian  layer  inter- 
spersed or  even  packed  with  vacuolated  cells  and  round  bodies, 
as  well  as  cells  with  deformed,  sometimes  monstrous  nuclei;  their 
large  numbers  as  well  as  the  acantholysis  of  the  intermediate 
cells,  gives  the  epidermis  a  disorganized  appearance  and  leads  to 
the  production  of  oozing  or  crusted  erosions.  The  scales  which 
persist,  appear  under  the  microscope  dotted  with  vacuoles  and 
pseudococcidia.  The  papillary  body  is  infiltrated  with  plasmocytes, 
sometimes  arranged  in  a  continuous  layer. 

The  threatened  contingency  of  cancer  necessitates  the  treatment 


230  KERATOSES 

of  Paget's  disease  by  [radical]  surgical  measures.   Radiotherapy  lias 
been  tried,  without  success. 

Precancerous  Dermatosis  of  Bowen  or  Dyskeratosis  Lenticularis 
et  Discoides.  —I  have  recommended  that  the  name  of  J.  T.  Bowen 
be  attached  to  an  essentially  chronic  and  progressive  derma- 
t  * » — i  —  first  described  by  him  in  1912.  It  appears  in  the  form  of 
lenticular  or  nummular  disks  (Fig.  ml.  later  patches  of  irregular 
shape,  covered  with  thick  scaly  crusts;  the  lesions  are  generally 
multiple,  non-symmetrical,  and  may  be  situated  anywhere.  Atro- 
phic spots,  resembling  Paget--  disease,  may  also  be  seen. 


Fig.  80.  -Dyskeratosis  <>f  Bowen.  showing  a  patch  composed  of  lenticular  and  dis- 
coid  lesions  on  the  internal  malleolus  of  a  woman,  aged  thirty-nine  years.  Personal 
observation,  1914. 

The  histological  structure  of  the  lesion  is  entirely  analogous  with 
that  of  Paget's  disease,  especially  in  regard  to  the  dyskeratosis  and 
the  vacuolization;  but  in  Bowen's  disease  a  well-marked  hyper- 
keratosis is  demonstrable.  The  differential  diagnosis  from  psoriati- 
form  eczematides,  tertiary  syphilides,  psoriasis,  senile  keratosis 
Lupus  erythematodes,  certain  forms  of  lichen,  etc.,  must  be  con- 
fin  mi  1  by  biopsy. 

In  one-half  of  the  reported  cases,  the  affection  was  observed  to 
degenerate  into  cancer.  Hence,  there  is  good  reason  for  expressly 
recommending  the  total  destruction,  or  better,  the  surgical  removal 
of  the  diseased  areas. 


CHAPTER  XII. 
PAPILLOMATOUS  AND  PROLIFERATING  DERMATOSES.1 

Papillary  proliferations  are  more  or  less  prominent  excres- 
cences, which  may  be  conical,  filiform,  or  resembling  a  cauliflower 
growth,  arranged  in  patches  or  spread  out  over  large  areas. 

They  must  not  be  interpreted  as  resulting  simply  from  the 
elongation  of  preexisting  normal  papilke;  on  a  given  surface  the 
normal  papillae  are  actually  infinitely  more  numerous  than  the 
excrescences  which  can  lodge  there.  Each  proliferation  really 
corresponds  to  several  papilla?,  united  on  the  same  axis  or  connective 
tissue  vascular  stalk. 

The  anatomical  conditions  which  give  rise  to  the  phenomenon 
of  papillary  proliferation  can  be  explained  in  three  different  ways: 
It  may  result  from  an  active  primary  proliferation  of  the  upper 
layer  of  the  derma  known  as  the  papillary  body,  or  from  a  primary 
proliferation  of  the  rete  Malpighii;  or  from  a  simultaneous  hyper- 
trophy of  these  two  layers.  As  a  general  rule,  as  was  demonstrated 
by  Auspitz,  the  Malpighian  hyperplasia,  known  as  acanthosis  or 
hyperacanthosis,  is  the  original  disturbance.  It  is  not  understood 
why  this  gives  rise  sometimes  to  a  simple  epidermic  papule  (for 
instance,  the  flat  juvenile  wart),  sometimes  to  a  papillomatous 
elevation  (for  instance,  the  papillary  wart). 

The  horny  layer  which  covers  the  proliferations  may  have  its 
normal  thickness,  or  it  may  be  thinned,  as  in  the  venereal  warts; 
or  on  the  contrary,  thickened  as  in  common  warts.  Hence,  there 
are  naked  proliferations  with  a  smooth  pink  surface;  others  have 
the  normal  color  of  the  skin;  still  others  are  of  a  grayish  yellow  color, 
firm  consistence,  and  evidently  hyperkeratotic.  The  latter  are 
named  verrucosities  or  verrucous  excrescences. 

No  very  distinct  boundary  line  can  accordingly  be  established 
between  the  two  dermatological  forms  of  keratoses  and  verrucosities. 

As  regards  the  term  papilloma,  this  approximately  corresponds  to 

1  In  the  original,  this  chapter  is  headed  vegetations  et  dermatoses  vegetantes. 
These  terms  cannot  be  literally  transcribed  into  English.  The  term  vegetation  con- 
notes a  papillary  proliferation  for  which  the  word  papilloma  was  formerly  used.  But 
as  Virchow  long  ago  pointed  out,  this  term  is  unscientific;  the  condition  is  not  a 
tumor  of  the  papillary  body  but  rather  a  proliferation  of  the  interpapiliary  epithelial 
processes  with  secondary  changes  in  the  papillae.  The  adjective  papillomatous, 
however,  may  properly  be  used  to  indicate  this  clinical  condition. — Ed. 


238     PAPILLOMATOUS  AND  PROLIFERATING  DERMATOSES 

that  of  vegetation,  and  like  the  latter  does  not  designate  a  dermato- 
logical  type  or  species,  but  an  objective  appearance  which  may  be 
brought  about  in  a  variety  of  dermatoses  and  tumors. 

Papillomatous  Dermatoses. — These  can  be  divided  into  three 
groups : 

A.  Essential  Papillomatous  Dermatoses. — Some  are  circumscribed, 
like  the  venereal  warts,  which  will  be  discussed  in  a  special  para- 
graph; the  same  is  true  for  common  wafts. 

The  verrucous  nevi  have  been  mentioned  in  connection  with  the 
circumscribed  keratoses  and  will  figure  again  among  the  nevi  in 
general  (XXXI). 

Others  are  generalized  or  regionally  diffused.  It  is  sufficient  to 
recall  the  hystrix  varieties  of  ichthyosis  and  generalized  hyper- 
keratosis. Under  this  heading  belongs  a  peculiar  cutaneous  dys- 
trophy, known  as  acanthosis  nigricans. 

B.  Accidentally  Papillomatous  Dermatoses. — Several  skin  diseases, 
of  infectious,  toxic,  or  indefinite  character,  may  present  proliferations 
as  a  form  of  eruption,  as  an  accidental  manifestation,  or  as  a  develop- 
mental phase.  From  the  diagnostic  point  of  view,  it  is  important 
to  compare  them  with  each  other. 

C.  Tropical  Proliferating  Dermatoses. — The  establishment  of  this 
group  may  appear  unscientific;  but  it  is  justified  in  the  present 
state  of  our  knowledge  and,  moreover,  is  convenient. 

VENEREAL  WARTS. 

Also  named  condyloma  acuminatum  and  popularly  known  [in 
France]  as  cauliflower  growths,  cock's  comb,  etc.,  venereal  warts 
are  agminated  papilliform  excrescences,  of  a  pinkish  or  grayish 
color,  having  their  seat  of  predilection  about  the  genital  organs  and 
the  neighboring  folds. 

In  men,  they  are  almost  exclusively  situated  in  the  glando- 
preputial  groove,  on  the  corona  glandis  and  the  frenum,  but  may 
affect  the  entire  prepuce  and  the  urethral  orifice. 

In  women  (Fig.  SI)  they  affect  the  vestibule  of  the  vulva,  the 
fourchette,  the  preputium  clitoridis  and  sometimes  cover  the  entire 
vulva,  the  genito-crural  folds,  the  anus  and  the  intergluteal  region. 

At  the  onset,  the  lesions  are  simple  pinkish  granules  or  branching 
elevations,  like  a  mole's  paw;  as  they  grow  they  form  tufts  of  fili- 
form or  lamellar  processes,  sometimes  reaching  a  length  of  several 
centimeters.  Whether  sessile  or  pedunculated,  the  warts  originate 
on  a  healthy  unthickened  skin  or  mucosa,  which  is  sometimes  irri- 
tated or  macerated.  In  women  who  are  neglectful  of  cleanliness, 
especially  in  case  of  gonorrhea  and  pregnancy,  they  finally  form 
enormous  mammillated  masses  the  size  of  a  fist,  bright  red  in  color, 


VENEREAL   WARTS 


239 


oozing  and  offensive.  They  cause  inconvenience  but  no  actual  pain. 
They  may  be  found  very  rarely  in  the  axillae  and  on  the  scalp,  but 
not  elsewhere. 

The  histology  of  these  growths  shows  a  very  pronounced  hyper- 
acanthosis,  with  abundant  karyokineses,  covering  filiform  and 
branched  connective-tissue  protuberances  which  are  traversed  by 
bloodvessels  with  large  lumina.  There  may  be  no  suggestion  of 
acute  inflammation  in  these  tissues.  The  granular  layer  is  dis- 
continuous, the  horny  layer  is  very  thin. 


Fig.  81. — Venereal  warts  of  the  vulva. 


The  etiology  has  not  been  elucidated;  these  growths  are  reputed 
to  be  contagious  and  auto-inoculable;  on  the  other  hand,  I  have 
certainly  known  them  to  appear  without  direct  contagion,  under 
the  influence  of  ordinary  irritations,  gonorrhea,  pregnancy,  etc. 
Their  kinship  to  common  warts  has  been  frequently  suspected,  but 
has  not  been  demonstrated. 

Treatment  by  attention  to  hygiene,  astringent  lotions,  bland 
powders,  pulv.  Sabinse  with  an  addition  of  salicylic  acid,  2  per  cent, 
will  usually  cause  them  to  wither,  though  not  to  disappear  entirely. 
Among  caustic  agents,  pure  carbolic  acid,  or  chromic  acid,  may 
prove  successful  when  the  warts  are  very  small. 

Voluminous  growths  require  ablation  with  the  scissors,  or  detach- 
ment with  the  forceps,  or  better  with  a  curette;  the  operation  is 
rather  painful.   Anesthesia,  local  or  general,  is  sometimes  necessary; 


240     PAPILLOMATOUS  AXD  PROLIFERATING  DERMATOSES 

inferior  spinal  analgesia  with  cocain,  which  deprives  the  region  of 
all  sensation,  would  be  very  valuable  in  extreme  eases  of  profuse 
and  exuberant  growth.  My  assistant  and  friend  Dr.  Chicotot  has 
successfully  removed  large  masses  of  condylomata  by  means  of 
radiotherapy. 

VERRUCA  VULGARIS. 

A  common  wart  is  a  papillary  hyperkeratotic  excrescence;  it  is 
typical  of  products  of  this  sort,  which  are  accordingly  known  as 
wartv  or  verrucous. 


Fig.   s2. — ( iomrnon  wails  on  the  hands  of  a  school-boy.     Note  near  the  left  thumb 
a  trail  of  four  waits  which  developed  on  a  scratch  made  with  a  pin. 


A  w;irt  consists  of  a  rather  prominent,  rounded  and  distinctly 
circumscribed  elevation,  from  the  size  of  a  pin-head  to  that  of  a 
small  bean,  usually  as  large  as  a  pea,  of  a  grayish,  yellowish  or  gray 
black  color,  with  a  mammillated  surface  sometimes  studded  with 
villous  protuberances,  of  a  hard  rough  consistence.  The  surround- 
ing skin  is  not  congested.  Some  warts  are  constricted  at  their  base, 
almost  pedunculated,  while  others  spread  out  and  are  not  much 
raised.    They  are  not  sensitive  or  painful  except  at  the  borders  of 


VERRUCA   VULGARIS 


241 


the  finger-nails  and  in  regions  exposed  to  pressure,  notably  on  the 
soles  of  the  feet. 

Warts  are  usually  multiple  and  have  their  seat  of  election  on  the 
dorsal  or  lateral  aspects  of  the  fingers  and  the  hand  (Fig.  82),  where 
they  may  become  confluent  in  patches,  they  also  occupy  the  peri- 
ungual or  subungual  groove;  more  rarely;  the  palm  of  the  hand  or 
fingers,  the  face,  the  eye-lids,  the  scalp  and  the  soles. 

Juvenile  flat  warts  are  probably  only  a  special  form  of  the  same 
affection  (p.  130). 


Fig.  83. — Plantar  warts  in  a  girl  aged  twenty  yeai 


Plantar  warts,  described  by  Dubreuilh  and  M.  Robert,  are 
noteworthy  on  account  of  their  extreme  tenderness  and  the  special 
treatment  which  they  require.  They  are  preferably  situated  on 
the  supporting  points  of  the  foot  and  at  first  sight  resemble  calluses, 
but  on  closer  examination,  they  are  seen  to  be  usually  composed 
of  filiform  growths,  arranged  in  a  cluster  and  surrounded  by  a  raised 
border  (Fig.  83).  They  can  be  cured  without  much  difficulty  by 
means  of  radiotherapy.  [I  have  encountered  some  plantar  warts 
which  are  extremely  resistant  to  treatment  and  have  yielded  only 
to  the  actual  cautery  or  to  applications  of  carbonic  acid  snow  after 
the  removal  of  the  thick  horny  layer  by  means  of  strong  salicylic 
acid  plasters  and  curettage.] 

All  warts  may  become  fissured  and  inflamed. 
16 


242     PAPILLOMATOUS  AND  PROLIFERATING  DERMATOSES 

These  formations  are  extremely  common  and  are  observed  espe- 
cially in  schoolboys,  in  youthful  individuals  doing  manual  labor, 
but  also  in  adults.  The  contagiousness  and  auto-inoculability 
of  warts,  always  asserted  by  the  laity,  have  been  proved  beyond 
a  doubt  by  the  experiments  of  Variot  and  others;  the  incubation 
lasts  longer  than  a  fortnight.  The  microbe  is  unknown;  the  bacillus 
porri  which  has  been  described,  has  not  been  proved  to  be  the 
causative  agent.  [Wile  and  Kingery  have  reproduced  epithelial 
hyperplasia  by  injection  of  the  filtrate  made  from  the  substance  of 
common  warts.] 

The  histology  of  Avarts  shows  an  enormous  increase  in  the  length 
of  single  papillae  or  of  groups  of  papilla?  and  of  their  vessels  and  a 
considerable  thickening  of  all  the  layers  of  the  epidermis;  there  is 
no  inflammatory  infiltration  in  the  cutis. 

The  treatment  must  aim  at  the  avoidance  of  cicatrices,  for 
the  warts  often  disappear  spontaneously.  It  is  most  advisable  to 
cauterize  them  carefully  with  the  galvanocautery,  or  with  a  very 
fine  point  of  thermocautery,  assisted  by  the  curette.  Carbonic 
acid  snow,  properly  applied,  is  likewise  very  successful.  Radio- 
therapy gives  remarkable  results,  without  pain;  but  it  requires 
great  caution,  especially  on  the  back  of  the  hand. 

Electrolysis  has  been  recommended  in  case  of  large  warts  and 
magnesium  ionization  when  they  are  very  numerous;  and,  very 
recently,  solar  light  condensed  by  means  of  a  large  lens.  It  is 
difficult  to  determine  the  efficacy  of  the  daily  administration  of  75 
centigrams  of  magnesium,  or  of  a  fewr  drops  of  tincture  of  thuja, 
or  of  arsenical  medication. 

Nitric  acid  does  not  deserve  the  favor  which  it  enjoys,  for  it  has 
caused  innumerable  burns  and  distressing  scars.  Less  powerful 
caustic  agents,  collodium,  plasters,  etc.,  are  apt  to  be  disappointing. 
The  juice  of  the  milk-wort  and  of  the  celandine,  very  persistently 
applied,  causes  the  warts  to  wither  and  drop  off. 

These  various  measures  may  prove  successful,  but  it  is  important 
to  keep  in  mind  a  surprising  but  undeniable  fact,  stated  by  many 
writers,  namely,  that  simple  suggestion  may  have  the  same  effect. 

[After  persisting  for  a  variable  period,  months  or  years,  warts 
generally  disappear  without  any  known  reason.] 

PAPILLARY  AND  PIGMENTARY  DYSTROPHY  OR  ACANTHOSIS 
NIGRICANS. 

This  disease  was  described  under  the  latter  name  by  Pollitzer 
and  Janovski,  in  1890,  after  I  had  observed  and  named  it  papillary 
and  pigmentary  dystrophy  [but  had  not  published  the  observation]. 
It  is  characterized  by  two  fundamental  phenomena:  (1)  a  roughened 
condition  of  the  skin,  with  scattered  or  agminated  papillomatous 


PAPILLARY  AND  PIGMENTARY  DYSTROPHY 


243 


elevations;  and  (2)  a  dark  pigmentation.  The  lesions  are  essentially 
regional,  ordinarily  symmetrical,  with  somewhat  diffuse  borders. 
In  order  of  frequency,  they  affect  the  axillae,  the  neck  and  nape  of 
the  neck,  the  ano-genital  region,  the  internal  aspect  of  the  thighs, 
the  fold  of  the  elbow,  the  popliteal  space,  the  umbilicus,  the  back 
of  the  hands,  the  areola  of  the  breasts  and  the  feet. 

The  roughened  condition  of  the  integument  is  due  to  an  exaggera- 
tion of  the  folds  and  fissures  and  does  not  disappear  on  stretching 
the  skin;  from  this  surface,  which  is  studded  with  papillary  pro- 
tuberances, of  a  brown  or  even  black  color  comparable  to  the  bark 
of  a  tree,  but  supple  and  sometimes  scaly,  arise  sessile  or  peduncu- 


Fig.  84. — Acanthosis  nigricans,  of  five  months'  standing;  portion  of  the  supra- 
clavicular fossa  of  a  man  aged  forty-two  years,  suffering  from  cancer  of  the  liver. 
After  a  cast  by  Baretta. 


lated  papillomatous  proliferations  (Fig.  84),  isolated  or  in  patches; 
on  the  free  border  of  the  eyelids  and  lips,  they  may  present  a  regular 
arrangement  like  the  teeth  of  a  comb. 

In  the  palmar  and  plantar  regions,  the  normal  papillary  ridges  are 
notably  exaggerated.  The  tongue  is  nearly  always  villous,  but  the 
mucosae  are  never  pigmented. 

The  finger  nails  are  brittle,  generalized  alopecia  is  common; 
pruritus  has  occasionally  been  noted. 

Acanthosis  nigricans  is  a  rare  disease,  about  sixty  [at  least  eighty 
to  a  hundred]  observations  have  been  reported  from  all  countries, 
with  a  slight  predominance  of  the  female  sex.    Its  principal  interest  is 


244     PAPILLOMATOUS  AND  PROLIFERATING  DERMATOSES 

due  to  the  fact  that  very  frequently,  in  about  two-thirds  of  the  cases, 
it.  is  associated,  as  was  first  pointed  out  by  me,  with  a  cancer  of  the 
abdominal  cavity,  primary  carcinoma  of  the  stomach  or  intestines, 
for  instance,  or  it  may  be  secondary  to  a  cancer  of  the  uterus,  or  the 
breast,  etc.  This  dermatosis  may  accordingly  put  the  physician  on 
the  track  of  a  latent  cancer,  as  has  happened  in  several  instances. 

It  begins  with  a  dirty-looking  pigmentation  of  the  neck  and  axilla?, 
or  the  appearance  of  one  or  several  warty  growths.  The  course 
is  rapidly  progressive,  sometimes  interrupted  by  remissions,  and 
cachexia  supervenes  in  less  than  a  year,  two  years  at  most. 

This  so-called  grave  form,  which  occurs  after  the  age  of  thirty 
years,  may  be  contrasted  with  a  juvenile  or  benign  form,  developing 
in  children,  not  related  to  cancer  and  only  half  as  frequent.  The 
symptoms  are  usually  not  so  marked  and  are  more  stationary;  the 
duration  is  indefinite,  but  the  general  health  is  not  affected.  The 
pathogenesis  is  unknown. 

The  atypical  forms  which  have  been  described,  can  be  admitted 
only  conditionally  and  may  possibly  be  referred  to  ichthyosiform 
hyperkeratosis  or  analogous  conditions. 

Accidentally  Proliferating  Dermatoses. — Proliferating  lesions  may 
occur  in  a  large  number  of  acute  or  chronic,  generalized  or  localized 
cutaneous  affections  of  very  variable  character.  The  territory,  or 
the  affected  tegumentary  region  is  sometimes  responsible.  It  is 
obvious,  although  this  fact  seems  to  have  escaped  the  attention 
of  most  writers,  that  the  peri-anal,  peri-genital,  inguinal,  axillary 
regions,  in  short  the  large  folds,  and  on  the  other  hand  the  borders 
of  the  orifices  of  the  face,  the  scalp  and  to  a  less  degree  the  extremi- 
ties are  especially  subject  to  the  occurrence  of  papillary  prolifera- 
tions. It  is  also  possible  that  certain  infectious  agents  have  a 
tendency  to  excite  proliferation;  several  pathogenic  protozoa 
apparently  possess  this  property. 

The  assumption  is,  moreover,  justified  that  the  papillomatous 
character  which  various  eruptions  may  accidentally  develop,  is 
referable  to  a  secondary  infection  or  a  microbic  symbiosis. 

Pemphigus  Vegetans  Gravis. — This  pathological  type  was  described 
in  L876  by  J.  Neumann,  who  considered  it  as  a  distinct  disease.  It 
is  characterized  by  bulla'  on  the  Moor  of  which  papillomatous 
growths  very  promptly  make  their  appearance.  The  eruption  is 
situated  especially  in  the  groins,  in  the  large  articular  folds  and  at 
the  circumference  of  the  mouth.  It  often  begins  on  the  buccal  or 
pharyngeal  mucosa,  or  at  the  genital  organs;  sometimes  at  the 
border  of  the  finger-nails  [or  at  the  anus]., 

The  initial  lesion  is  a  bulla,  often  flaccid  and  seropurulent  from 
the  first,  which  dries  into  a  crust  and  may  heal  locally  or  spread 
at  the  periphery.     At  the  end  of  five  or  six  days,  the  floor  of  some 


PAPILLARY  AND  PIGMENTARY  DYSTROPHY  245 

or  most  of  the  bullae  becomes  excoriated,  begins  to  proliferate, 
undergoes  a  papillomatous  change  and  secretes  an  offensive  pus 
under  a  brownish  crust.  There  is  a  striking  resemblance  between 
these  lesions  and  hypertrophic  mucous  patches.  Serpiginous 
extension  and  confluence  of  the  lesions  give  rise  to  extensive  sur- 
faces, mammillated  in  the  center  and  pustular  at  the  circumference. 
Healing  is  followed  by  brownish  and  roughened  macula?. 

In  severe  cases,  the  mouth  is  lined  with  very  painful  diphtheritic 
erosions,  the  lips,  all  the  articular  folds  and  the  regions  where  skin 
rests  upon  skin,  sometimes  a  considerable  portion  of  the  head, 
trunk  and  limbs,  as  well  as  the  mucous  membranes,  are  covered 
with  fetid  and  painful  suppurating  vegetating  ulcerations.  Fever 
has  been  repeatedly  noted.  Death  supervenes  from  cachexia  in 
two  to  six  months,  sometimes  later. 

The  histology  of  the  initial  bulla  is  that  of  genuine  pemphigus.  In 
the  papillomatous  stage,  the  excrescences,  which  may  reach  a  height 
of  6  to  10  millimeters,  are  covered  with  a  greatly  thickened  rete 
Malpighii.  In  the  latter,  or  in  the  proliferating  papillary  body,  or 
between  these  two  tissues,  small  abscesses  are  demonstrable,  with 
polynuclear  leukocytes  and  numerous  eosinophile  cells.  Fosino- 
philia  have  been  demonstrated  in  the  blood  and  various  lesions  of 
the  nervous  system  and  the  viscera  have  been  found  at  autopsies. 
Pemphigus  vegetans  gravis  is  observed  in  both  sexes,  especially  in 
adults,  but  it  is  a  rare  disease.  Its  nature  is  unknown.  Its  unfav- 
orable course  and  gloomy  prognosis  suggest  that  it  is  merely  a 
variety  of  genuine  pemphigus,  which  has  become  papillomatous 
through  a  superadded  infection  with  an  undetermined  agent.  G. 
Pernet  (1907)  is  undoubtedly  right  in  claiming  that  pemphigus 
vegetans  is  not  a  definite  pathological  variety,  but  is  referable  to  a 
number  of  infectious  agents  among  which  he  states  the  Bacillus 
pyocyaneus  to  be  especially  common.  [The  pyocyaneus,  however, 
is  extremely  common  everywhere!] 

Pemphigus  Vegetans  Benignus. — Beside  the  above  described  almost 
invariably  fatal  form,  an  eruption  is  sometimes  observed  having 
very  similar  lesions,  but  advancing  in  successive  attacks,  with 
preservation  of  a  good  general  condition  and  terminating  in  recovery 
after  a  variable  length  of  time.  In  this  benign  form,  the  mouth, 
lips  and  large  folds  are  not  so  much  involved ;  whereas  the  skin  of  the 
extremities  and  the  large  surfaces  of  the  trunk  (Fig.  85)  suffers  more. 

There  is  a  striking  similarity  with  bromoderma  and  iododerma 
vegetans. 

The  coexistence  of  polymorphous  eruptive  lesions  and  eosinophilia 
of  the  blood  has  often  been  interpreted  as  pointing  to  a  prolifera- 
tive form  of  Duhring's  disease.  Non-recurrent  cases  have  on  the 
other  hand  suggested  the  idea  of  erythema  bullosum  vegetans. 


240    PAPILLOMATOUS  AND  PROLIFERATING  DERMATOSES 

On  the  whole,  the  scries  of  forms  of  pemphigus  vegetans  presents 
the  same  difficulties  of  classification  as  the  bullous  eruptions  in 
general.  Some  dermatologists  simplify  the  problem  by  recognizing 
a  dermatitis  vegetans  capable  of  assuming  every  imaginable  degree. 

Treatment.  The  treatment  is  that  of  infected  erosions  of  all 
kinds:  prolonged  local  baths,  softening  or  mildly  antiseptic  moist 
dressings,  with  hypochlorites,  permanganate,  etc.,  painting  with 
iodin  solution,  application  ^of  absorbent  powders.  Arsenic  and 
especially  arsenobenzol  have  yielded  some  very  satisfactory  results. 
Radiotherapy  is  likewise  successful. 


Fig.  85. — Benign  pemphigus  vegetans;  patch  of  five  months'  standing  in  a 
child  aged  five  years;  blood  withdrawn  from  the  lesions  contained  30  per  cent.  6f 
eo  M,.  iphiles. 


Proliferating  Pyodermatitides. — Under  the  name  of  chronic  pustular 
dermatitis  in  feci  with  peripheral  extension,  later  as  pyodermatitis 
vegetans,  Hallopeau  I L889  ISDN)  described  a  form  which  is  pustular 
from  the  onset,  benign  in  character,  slowly  progressive  and  very 
protracted,  as  a  variety  of  Neumann's  pemphigus  vegetans. 

The  name  of  pyodermatitis  vegetans  might  also  be  applied  to  the 
cases  in  which  an  impetigo  or  an  infected  herpes,  etc.,  give  rise  to 
papillomatous  proliferations,  which  is  especially  apt  to  occur  in 
the  folds.     (Sec  Syphiloid  Dermatitis  Vegetans.) 

Papillomatous  and  Verrucous  Elephantiasis.- — In  all  forms  of 
elephantiasis,  especially  in  elephantiasis  nostras  and  still  more  in 
the  secondary  elephantiases,  the  cutaneous  surface,  chiefly  on 
the  lower  part  of  the  legs  and  on  the  feet,  may  become  roughened, 


PLATE    I 


Vegetative  Syphilides  of  the  Secondary  Stage. 

The  patient  presented   at  the   same    time  vegetative   mucous  patches  upon 
the  lips  and   under  the  tongue. 


PAPILLARY  AND  PIGMENTARY  DYSTROPHY  247 

mammillated,  covered  with  pink  or  whitish  proliferations,  or  with 
gray  or  blackish  hyperkeratotic  verrucosities. 

Hypertrophic  Lichen  Corneus.  —  This  affection,  which  is  very 
easily  recognized  after  seeing  a  case,  has  been  described  above 
(p.  140). 

Papillomatous  Syphilides. — These  are  either  secondary  or  tertiary. 
The  secondary  kind  constitute  a  modification  of  the  lenticular  or 
especially  the  nummular  papules.  Generally  isolated  or  not 
numerous,  they  occupy  the  nape  of  the  neck  (Plate  I),  the  thorax 
or  the  face  and  assume  the  shape  of  distinctly  circumscribed, 
sometimes  crusted  papillomatous  patches,  0.5  cm.  thick,  from  1  to 
4  cm.  wide,  developing  gradually  and  leaving  a  dyschromic  spot. 
They  are  not  rare  in  the  nasogenial  furrow  and  at  the  fold  of  the 
chin. 

Hypertrophic  mucous  patches  belong  entirely  under  this  heading. 
The  syphilitic  patches  of  Legendre  are  related  lesions. 

Tertiary  proliferating  syphilides  may  develop  on  a  variety  of 
ulcerations,  especially  on  tuberculo-gummous  syphilides.  In  these 
cases,  papillomatous  or  fungoid  papillomatous  growths  are  seen 
arising  from  the  depths  of  solutions  of  continuity,  radically  altering 
the  appearance  of  the  lesions.  This  contingency  must  be  kept 
in  mind,  for  tertiary  proliferating  syphilides  are  often  confused 
especially  with  epitheliomas.  They  are  observed  more  particularly 
in  hairy  regions,  the  scalp,  beard,  axilla,  pubis  and  on  the  lower 
limbs;  they  may  accompany  an  elephantiatic  state. 

Papillomatous  and  Verrucous  Tuberculosis. — The  cutaneous  tuber- 
culous lesions  are  proliferative  under  various  conditions.  Irregular 
patches  of  ulcerative  papillomatous  tuberculosis  may  be  observed, 
although  not  commonly,  either  at  the  circumference  of  the  mouth 
or  at  the  anus,  or  finally  at  the  vulva,  where  they  are  sometimes 
considered  as  part  of  the  syndrome  of  vaginal  lupus.  Pinkish  or 
papillomatous  proliferations  arise  from  the  floor  or  the  border  of 
the  ulceration.     The  course  is  extremely  slow. 

From  time  to  time,  cases  of  frambesif orm  tuberculosis  are  reported, 
representing  large  surfaces  covered  with  villous  proliferations  and 
interspersed  with  irregular  ulcers  and  miliary  abscesses.  A  lesion 
of  this  kind,  which  covered  almost  the  entire  extent  of  the  thigh 
and  buttock  was  observed  by  myself  and  Brocq. 

Tuberculosis  Verrucosa. — Tuberculosis  verrucosa  is  more  common, 
and  is  entitled  to  a  detailed  description.  It  is  usually  found  on 
the  hand,  on  the  fingers  or  on  the  wrists;  it  has  a  certain  predilec- 
tion for  the  radial  side  of  the  hand  and  especially  for  the  thumb 
(Fig.  86) ;  but  it  is  also  met  with  on  the  elbows,  the  knees,  in  the 
peri-anal  region,  on  the  buttocks,  the  feet,  the  neck  and  even  on- 
the  face.     It  appears  in  the  form  of  a  single  patch,  of  nummular 


248     PAPILLOMATOUS  AND  PROLIFERATING  DERMATOSES 

dimensions  or  more  extensive,  of  a  round,  oval  or  multilobular 
configuration,  sometimes  elongated,  following  a  fold  of  the  skin. 

When  the  focus  is  small,  it  is  a  papillomatous  or  hyperkeratotic 
elevation,  somewhat  resembling-  a  wart;  but  its  base  is  always 
surrounded  by  a  red  or  purplish  areola;  pressure  will  occasionally 
cause  a  small  drop  of  pus  to  escape. 

In  its  completely  developed  state,  a  patch  of  verrucous  tuber- 
culosis is  composed  of  three  zones:  at  the  circumference,  a  smooth 
and  level  erythematous  zone;  next,  a  more  elevated,  purplish  or 
brownish,  papillomatous  median  zone,  interspersed  with  small 
adherent  crusts  or  cribriform  ulcers,  from  which  droplets  of  pus 
can  be  squeezed  out;  finally,  a  central  portion,  which  is  sometimes 
cicatricial  and  depressed,  sometimes  protuberant  and  studded  with 
gray  or  yellowish  horny  verrucosities,  separated  by  grooves  and 
fissures.  The  base  of  the  patch  is  indurated,  of  fibrous  rather  than 
edematous  consistence. 


Fig.  86. — Tuberculosis  verrucosa.     After  a  cast  of  Baretta's  in  the  Museum  of  the 
St.  Louis  Hospital. 

After  healing  has  occurred,  the  cicatrix  is  flat  and  white,  or 
undulating  and  interspersed  with  light  tracts  on  a  purplish  back- 
ground. It  is  adherent  when  the  cutaneous  lesion  was  derived 
from  a  deep,  bony,  or  glandular  focus,  etc. 

The  diagnosis  of  tuberculosis  verrucosa,  based  on  its  objective 
features,  its  seat,  the  conditions  under  which  it  appears,  and  its 
slow  course,  is  usually  easy.  Examination  by  biopsy,  bacteriolog- 
ical examination  and  experimental  inoculation  will  serve  to  confirm 
it  in  those  cases  where  syphilis,  epithelioma,  sporotrichosis,  the 
blastomycoses,  etc.,  cannot  be  readily  excluded. 

Anatomical  tubercles  may  be  regarded  as  a  verrucous  tubercu- 
losis, of  small  dimensions,  but  highly  virulent. 

Discussion  of  the  etiology  and  treatment  of  these  affections  will 
be  found  elsewhere  in  this  book  (p.  552). 


PROLIFERATING  TROPICAL  DERMATOSES  249 

Proliferating  or  Papillomatous  Epithelioma. — This  is  observed 
chiefly  in  the  face,  especially  on  the  lips  or  on  the  mouth  and  also 
on  the  external  genital  organs. 

This  papillomatous  epithelioma  often  develops  on  a  basis  of 
senile  keratosis  or  leukoplakia.  Surgical  excision,  as  promptly  as 
possible,  is  indicated. 

Mycoses,  Sporotrichoses,  Etc. — An  appearance  identical  with  or 
closely  analogous  to  that  of  papillomatous  syphilides,  papillomatous 
epithelioma,  and  especially  tuberculosis  verrucosa,  may  be  pro- 
duced by  a  blastomycotic  or  sporotrichetic  infection.  At  the 
present  day,  when  the  frequency  of  the  mycotic  dermatoses  has 
been  established,  especially  through  the  work  of  de  Beurmann  and 
Gougerot,  it  would  be  a  serious  error  not  to  take  this  possibility 
into  consideration,  whenever  it  is  plausible.  The  investigations 
required  for  its  verification  will  be  discussed  elsewhere. 

Papillomatous  Toxicodermas. — Iododerma  papillomatosum  may 
appear  in  any  region  of  the  integument,  beginning  as  a  purulent 
bulla  with  an  inflammatory  base,  which  becomes  papillomatous  at 
the  center  and  rapidly  extends  peripherally.  The  usually  multiple 
lesions  become  confluent  in  sometimes  rather  extensive  patches; 
their  pustular  margin  is  suggestive. 

Bromoderma  papillomatosum  greatly  resembles  the  iodide  erup- 
tion, but  is  softer,  more  fungoid,  with  less  tendency  to  suppurate. 

In  both  cases,  in  the  absence  of  definite  information,  iodin  or 
bromin  may  be  looked  for  in  the  urine.  It  is  noteworthy,  however, 
that  these  eruptions  may  persist  several  weeks  after  the  last  inges- 
tion of  the  drug.  [In  the  case  of  nursing  infants  the  eruption  may 
develop  in  consequence  of  a  bromide  or  iodide  mixture  taken  by 
the  nurse.] 

PROLIFERATING   TROPICAL   DERMATOSES. 

A  group  of  diseases  endemic  in  tropical  countries  is  characterized 
by  proliferating  or  ulcero-vegetative  eruptions. 

Their  objective  appearance  is  sometimes  typical,  but  they  are 
nevertheless  apt  to  be  confused,  especially  with  tuberculosis  and 
syphilis.  In  a  general  way,  it  may  be  stated  that  tuberculosis 
verrucosa  differs  by  its  slow  course  and  the  small  number  of  foci 
which  never  heal  spontaneously;  and  syphilis,  by  its  polymorphous, 
protean  manifestations,  which  do  not  spare  the  mucosae  and  which 
follow  a  definite  course. 

In  most  cases,  a  valuable  diagnostic  indication  is  furnished  by 
the  mode  of  origin,  the  disease  appearing  either  in  the  country 
where  it  prevails,  or  in  returning  travellers. 


250     PAPILLOMATOUS  AXD  PROLIFERATING  DERMATOSES 

Oriental  Boil  (Biskra Button). — In  its  developed  stage,  the  Biskra 
button  (p.  648)  is  a  round  or  oval  ulceration,  the  size  of  a  small 
coin  or  several  centimeters  in  diameter,  with  festooned  outlines, 
concealed  under  a  very  adherent  yellow-brown  crust  and  bordered 
by  an  erythematous  margin  (Fig.  186). 

Under  the  crust  is  found  a  turbid  serous  fluid,  an  ulcer  with 
perpendicular  eroded  ragged  margins  and  a  bright-red,  granular, 
mannnillated  and  papillomatous  floor.  On  this  floor  and  around 
the  circumference,  purulent  yellow  points  may  be  found.  The 
base  is  congested  and  infiltrated.  Lymphangitis  and  phlebitis  are 
frequent  complications.  The  glands  are  as  a  rule  enlarged  and 
painful. 

Spontaneous  cicatrization  is  slow,  requiring  several  months. 
The  scar  which  persists  is  depressed,  smooth,  colorless  or  of  a  dusky 
red  hue,  with  peripheral  pigmentation. 

The  histological  structure  is  that  of  a  granuloma,  with  predomi- 
nance of  mononuclears,  a  few  plasmoeytes  and  foci  of  necrosis. 
The  papillary  hypertrophy  is  considerable,  with  hyperacanthosis 
and  parakeratosis. 

Yaws. — The  eruptive  lesion  in  yaws  or  Frambesia  tropica,  in  the 
primary  lesion  as  well  as  in  the  generalized  eruption,  always  consists 
at  the  onset  of  a  rose-red  conical  elevation,  with  a  crusted  necrotic 
center;  the  crust  is  discharged,  the  lesion  extends  and  becomes 
papillomatous  (p.  646). 

The  patches  may  attain  a  diameter  of  1  to  6  cm.;  they  are  covered 
with  an  adherent  brown  crust,  or  a  fetid  secretion  in  the  macerated 
areas.  The  proliferations  are  grayish  or  pinkish ;  there  is  no  ulcera- 
tion or  loss  of  substance.  The  center  has  a  tendency  to  collapse; 
the  circumference  is  often  the  seat  of  a  bullous  elevation.  Con- 
fluence gives  rise  to  the  formation  of  large  patches  with  polycyclic 
outlines.     The  eruption  is  usually  painless. 

A  spontaneous  cure  may  occur  at  any  stage  of  development;  it 
manifests  itself  by  the  lesions  becoming  flattened  and  undergoing 
absorption.  Only  pigmented  macules  are  left  behind,  and,  as  a 
rule,  no  cicatrices. 

The  site  of  election  of  the  eruptions  in  yaws  is  around  the  natural 
orifices,  at  the  lips,  the  nostrils,  in  the  genital  regions  and  in  all 
body  folds.  But  they  may  be  very  extensive  and  profuse,  suggest- 
ing hypertrophic  mucous  patches  and  papulo-crusted  syphilides. 
In  the  palmar  and  plantar  regions,  the  proliferations  are  covered 
with  hyperkeratoses  and  are  very  painful.  The  mucous  mem- 
branes always  remain  free. 

Histology  shows  an  abundant  infiltration  of  plasmoeytes,  without 
epithelioid  cells  or  giant  cells;  it  occupies  the  papillary  body  and 
the  papilla-;  the  latter  are  enormously  hypertrophied  and  traversed 


PROLIFERATING  TROPICAL  DERMATOSES  251 

by  dilated  vessels.  Hyperkeratosis  is  considerable  and  parakeratosis 
is  common. 

Elsewhere  mention  will  be  made  of  the  proliferative  papilloma- 
tous ulcers  of  Boubas,  which  are  accompanied  by  similar  lesions  of 
the  mucous  membranes  (p.  650). 

Ulcerating  Granuloma  of  the  Genital  Organs  (Granuloma 
Inguinale,  Granuloma  Venereo,  Groin  Ulceration). — This  is  a  chronic 
and  contagious,  ulcerative  or  papillomatous  dermatosis,  venereal 
in  most  cases,  occurring  in  all  countries,  notably  in  South  America, 
especially  in  Guiana  and  Brazil,  as  well  as  in  New  Zealand  and 
the  East  Indies;  a  few  cases  have  been  reported  in  England.  It 
attacks  adults  of  both  sexes  and  all  races. 

Beginning  with  a  nodule  on  the  genital  organs,  it  spreads  in  the 
form  of  an  ulcerative  granular  patch  to  the  groins,  the  pubis,  the 
perineum  and  invades  the  mucosae.  The  borders  are  distinctly 
marked;  the  surface  is  riddled  with  papillomatous  elevations,  super- 
ficially ulcerated,  of  a  bright  red  color;  it  secretes  an  offensive  serous 
fluid;  the  center  becomes  cicatricial.  This  lesion  lasts  many  years, 
without  causing  glandular  enlargement  or  giving  rise  to  cachexia. 

Histologically,  it  is  a  plasmoma  with  enormous  hypertrophy  of 
the  papillae,  analogous  to  yaws.  According  to  a  very  recent  and 
excellent  contribution  by  Souza  Araujo  (Rio  de  Janeiro,  1917),  the 
causative  agent  seems  to  be  the  germ  discovered  by  Donovan  in 
1905,  which  has  since  been  isolated  and  cultured  and  is  known  as 
Calymmato-bacterium  grannlomatis.  This  encapsulated  bacillus  is 
Gram-negative,  takes  the  Giemsa  stain  and  is  abundantly  present 
in  the  cells  of  the  granuloma  and  in  the  secretion.  The  specific 
treatment  of  the  disease  consists  of  intravenous  injections  of 
tartar  emetic. 


CHAPTER  XIII. 

TUBERCLES  AND  TUBERCULO-ULCERATIVE 

DERMATOSES. 

In  the  dermatological  [as  distinguished  from  the  pathological] 
sense  of  the  word,  tubercles  are  pathological  products  of  the  cutis, 
solid  (that  is,  without  fluid  contents),  circumscribed,  rounded,  more 
or  less  prominent,  of  slow  development,  deep  and  especially  damag- 
ing to  the  cutis. 

This  last  named  and  most  essential  characteristic  involves  a 
frequent  tendency  of  tubercles  to  ulcerate  and  almost  always  to 
leave  a  cicatrix  in  their  place,  with  or  without  previous  ulceration. 
This  fact  is  expressed  in  the  statement  that  tubercles  do  not  undergo 
resolution. 

The  differentiation  of  tubercular  eruptions  from  papules,  nodules 
and  tumors,  must  first  be  clearly  understood.  Papules  are  dis- 
tinguished from  tubercles,  not  so  much  by  their  size  and  prominence, 
as  by  their  more  rapid  development  and  tendency  to  absorption,  a 
papule  leaving  no  scar  behind  it  after  it  has  healed.  Doubtful  or 
intermediate  lesions  are  met  with,  however,  which  may  be  named 
papulo-tubercles;  some  dermatologists  use  this  term  for  giant  papules. 

Nodes  and  nodules  are  hypodermic  newformations,  whereas 
tubercles  are  dermic.  But,  although  morphologically  distinct, 
tubercles  and  nodules  often  result  from  the  same  process,  justifying 
the  terminology  of  Besnier,  who  defines  nodules  as  hypodermic 
tubercles. 

Certain  tubercles  simulate  tumors,  or  approximate  these  by  their 
size,  prominence,  confluence  in  raised  and  mammillated  patches, 
course,  etc.  Tubercles,  however,  after  a  more  or  less  prolonged 
duration,  have  a  tendency  to  become  replaced  by  a  cicatrix;  tumors, 
on  the  contrary,  are  persistent  or  indefinitely  progressive,  although 
these  features  are  not  invariable. 

In  reality  the  basis  of  differentiation  is  that  the  name  of  tumors 
is  given  to  newgrowths  of  entirely  unknown  character,  while 
dermic  neoplasms  of  a  known  chronic  infectious  origin  are  known 
as  tubercles. 

The  histological  criterion  is  decisive  in  this  connection.  As  will 
be  seen  further  on  (Chapter  XXXI),  tumors  are  composed  of 
heterotopic  tissues  which  replace  the  normal  tissue  of  the  affected 


TUBERCULO-ULCERATIVE  DERMATOSES  253 

region.  Tubercles,  on  the  contrary,  are  formed"  by  collections  of 
inflammatory  cells  of  various  types,  more  or  less  coherent  and 
extensive,  infiltrating  the  strands  of  the  derma  which  may  have 
undergone  degenerative  changes. 

The  abundance  and  density  of  these  cellular  infiltrations  and 
the  degree  of  preservation  of  the  dermic  stroma  are  variable  and 
account  for  the  more  or  less  marked  prominence,  firmness  or  soft- 
ness of  the  tubercles.  Their  constitution  also  serves  to  explain 
their  capacity  of  undergoing  absorption,  although  usually  not 
without  atrophy  and  sclerosis,  that  is,  not  without  a  cicatrix. 

In  some  tubercles,  the  infiltration  has  a  marked  tendency  to 
cellular  necrosis,  disintegration  and  dissolution  naturally  following; 
the  outcome  is  a  limited  and  often  very  deep  ulceration. 

The  differential  diagnosis  between  a  tuberculo-ulcerative  process 
and  primary  ulcerations  rests  on  its  at  first  neoplastic  and  second- 
arily destructive  course;  furthermore,  on  the  usual  persistence  of 
tubercular  remnants  at  the  base  and  in  the  circumference  of  the 
ulcer,  indicated  by  a  special  hardness  in  the  case  of  tertiary 
syphilides  or  actinomycosis,  by  a  peculiar  softness  in  the  case  of 
ulcerative  lupus,  etc. 

Indurated  follicular  pathological  products,  whether  suppurative 
like  furunculosis  and  carbuncle,  or  dry  like  keloid  acne,  do  not  figure 
in  this  book  among  the  tubercles,  but  in  the  chapter  on  the  folli- 
culoses  (Chapter  XIX). 

TUBERCULO-ULCERATIVE   DERMATOSES. 

The  presence  of  true  tubercles  or  of  a  tuberculo-ulcerative  lesion 
having  been  recognized,  it  is  necessary  to  think  in  the  first  place  of 
the  great  chronic  infectious  diseases,  i.  e.,  syphilis,  tuberculosis 
and  leprosy;  secondarily,  of  the  more  uncommon  mycotic  infections, 
such  as  sporotrichosis,  the  blastomycoses  and  actinomycosis,  for 
which  the  reader  is  referred  to  another  chapter  (XXVIII) ;  finally, 
there  is  a  group  of  dermatoses  manifesting  itself  by  non-ulcerative 
tubercles,  the  lupoid  and  analogous  cutaneous  sarcoids,  which  are 
undoubtedly  of  infectious  character  and  probably  belong  to  the 
tuberculides,  although  this  has  not  been  positively  established. 

Only  the  following  types  will  be  described  in  this  connection: 
(1)  The  tubercular  syphilides,  (2)  the  tubercles  of  lupus,  (3)  the 
tubercles  of  leprosy,  (4)  the  cutaneous  sarcoids  or  lupoids  and  granu- 
loma annulare. 

Tubercular  Syphilides. — From  the  purely  morphological  view- 
point, leaving  the  course  entirely  out  of  consideration,  the  initial 
symptom  of  syphilis,  the  hard  chancre,  might  be  said  to  present 
the  chief  attributes  of  a  tubercle. 


2.14     TUBERt  'LES  AND  TUBERCULO-ULCERATIVE  DERMATOSES 

Genuine  tubercular  syphilides,  however,  are  symptoms  of  the 
tertiary  stage. 

The  syphilitic  tubercle  constitutes  the  typical  form  of  a  tubercle. 
It  is  a  dry  elevation,  brownish  or  grayish  red  in  color,  the  average 
size  of  a  lentil,  projecting  from  1  to  5  mm.,  with  rounded  contours, 
very  hard  on  palpation,  entirely  painless.  On  vitropressure  (mean- 
ing when  the  tubercle  is  com  prosed  under  a  glass  slide),  it  is  seen 
to  be  opaque  and  frequently  pigmented. 

The  subjoined  illustration  (Fig.  87)  conveys  an  idea  of  its  histo- 
logical structure. 


Fig.  87.  -Histologyof  syphilitic  tubercle.    Tuberculo-squamous  tertiary  syphilis. 

The  infiltrate  (i,  i)  is  discontinuous,  composed  of  lymphoid  cells  and  plas- 
mocytes  without  gianl  cells  or  epithelioid  •■ell-:  it  forms  cuffs  which  surround  ihe 
ramifications  of  the  bloodvessels;  these  are  for  the  most  pari  dilated,  inflamed,  or 
sclerotic  Between  the  infiltrates  the  dermic  tissue  (d)  is  thickened,  fibrous  and 
sclerotic,  which  explains  the  hardness  of  the  lesion.  The  horny  epidermis  (c)  is  greatly 
thickened  and  coherent;  at  (s)  it  is  split  and  shows  a  tendency  to  desquamation. 
The  Malpighian  layer  and  the  papillae  are  preserved, excepl  at  (u),  where  the  inflam- 
mation is  more  active  and  ulceration  is  under  way.  See  Pathological  Anatomy  of 
the  Syphilides,  p.  628.      X  20. 


A  tubercular  syphilitic  begins  as  a  single  lesion  or  as  a  small 
coherent  group  of  tubercles  which  spread  out,  progressing  excen- 
trically  and  multiply  within  a  few  weeks;  in  this  way,  more  or 
less  extensive  patches  are  formed  or  even  larger  areas  may  become 
involved.  Usually,  however,  the  central  lesions  flatten,  fade  and 
undergo  sclerotic  changes,  forming  cicatrices  even  in  the  complete 
absence  of  ulceration,  while  new  lesions  make  their  appearance 
at   the   periphery.     This   centrifugal    or   serpiginous   development 


TUBERCULO-ULCERATIVE  DERMATOSES 


255 


gives  rise  to  circinate  forms;  these  are  by  no  means  complete  rings, 
but  generally  more  or  less  semicircular,  having  a  diameter  of  2  to 
12  cm,  or  kidney-shaped  and,  through  confluence,  polycyclic  con- 
figurations (Fig.  88).  Their  border  is  marked  by  a  usually  inter- 
rupted zone  of  isolated  or  confluent  tubercles. 

Occasionally,  the  eruption  of  syphilitic  tubercles  may  present  this 
circinate  arrangement  from  the  start.  In  these  cases,  the  central 
area  shows  normal  skin.  When  the  circination  is  the  result  of 
centrifugal  extension  of  the  process,  its  center  is,  on  the  contrary, 
often  depressed,  slightly  adherent  and  not  readily  folded;  it  may  be 
distinctly  sclerotic  or  interspersed  with  cicatricial  stars  and  streaks; 
its  color  is  earthy  rather  than  white,  often  mottled  with  purplish  or 


Fig.  88. — Tuberculo-circinate  syphilides  of  the  left  hip. 


brownish  shades.  The  reappearance  of  tubercles  on  the  cicatrix 
is  rare  in  the  tuberculo-circinate  syphilides;  whereas,  on  the  con- 
trary, this  occurrence  is  frequent  in  lupus  serpiginosus. 

After  recovery,  the  tubercular  border  has  disappeared,  but  the 
persisting  cicatrix  may  still  present  a  very  characteristic  appear- 
ance. 
Various  forms  of  tubercular  tertiary  syphilides  may  be  described : 
The  tuber culo-squamous  form,  with  grayish,  more  or  less  abun- 
dant, adherent  scales,  is  very  common,  more  so  than  the  tuberculo- 
psoriatiform  variety,  with  abundant  nacreous  scales  and  barely 
perceptible  infiltration;  it  is  distinguished  from  psoriasis  by  the 
small  number  of  the  patches,  their  configuration  [and  location]  and 
sometimes  by  the  presence  of  cicatrices. 


256     TUBERCLES  AND  TUBERCULO-ULCERA TI VE  DERMA TOSES 

When  the  tubercles  become  eroded  and  covered  with  an  adherent 
dirty  brownish  crust,  the  outcome  is  the  tuberculo-crusted  form, 
which  is  connected  by  imperceptible  transition  with  the  tuberculo- 
ulcerative  form.  In  the  latter,  the  crusts  are  found  to  cover  round, 
perpendicular-walled  ulcerations  containing  a  sanious  pus. 

These  various  forms  are  usually  circinate.  There  also  occurs, 
notably  on  the  nose,  the  forehead  and  chin,  a  .superficial  tubercular 
syphilide,  composed  of  large,  smooth,  dusky  red  tubercles,  which 
may  be  agminated  or  sometimes  confluent  in  an  infiltrated  patch. 
The  latter  is  apt  very  closely  to  simulate  rosacea  in  the  stage  of 
rhinophyma;  when  it  appears  that  the  center  has  a  tendency  to 
become  sclerotic  and  depressed,  this  fact  furnishes  a  valuable 
indication  in  favor  of  syphilis;  but  a  careful  investigation  may  be 
necessary. 

Certain  tertiary  syphilitic  ulcers,  characterized  by  their  indurated 
base,  sharp  outlines  and  their  course,  may  be  considered  as  tuber- 
culo-ulcerative  syphilides  with  indistinct  and  primarily  confluent 
tubercles  (Fig.  98).  The  same  remark  applies  to  chancriform 
syphiloma. 

The  diagnosis  of  tubercular  syphilides  can  very  often  be  based 
upon  their  objective  appearance;  not  uncommonly,  they  put  the 
alert  observer  on  the  track  of  an  undetected  long-standing 
syphilis.  In  other  cases,  the  diagnosis  will  be  confirmed  by  the 
complete  examination  of  the  patient,  the  anamnesis  and  sero- 
diagnosis,  with  examination  by  biopsy  if  necessary. 

Specific  treatment  will  cure  these  lesions  in  from  two  to  four  weeks. 

Lupus  Tubercles. — Lupus  vulgaris  is  one  of  the  most  attenuated 
forms  of  bacillary  tuberculosis  of  the  skin.  Its  characteristic 
lesion  consists  of  a  tubercle  possessing  certain  special  features. 

In  order  to  avoid  the  ambiguousness  resulting  from  the  double 
meaning  of  the  word  tubercle— bacillary  tubercle  and  dermatological 
tubercle — it  has  been  recommended  to  designate  the  eruptive  lesion 
of  lupus  as  lupoma. 

All  cases  of  lupus  begin  as  a  minute  lupoma,  which  grows 
to  the  size  of  a  pin-head,  then  of  a  lentil,  while  other  similar 
lesions  more  or  less  rapidly  originate  in  its  immediate  circumfer- 
ence or  in  its  vicinity.  Sometimes,  lupus  begins  in  two  or  three 
distinct  foci,  or  exceptionally  in  the  form  of  an  extensive  eruption. 
Lupomas  may  accordingly  be  found  isolated  or  conglomerated  in 
patches  around  which  a  few  aberrant  lesions  are  apt  to  appear. 

Typical  I  lipomas  are  rounded  tubercles,  the  size  of  a-  pin-head 
to  that  of  a  large  pea,  more  or  less  prominent,  or  on  the  contrary, 
perfectly  level  with  the  normal  skin;  their  color  is  a  yellowish, 
sometimes  purplish  or  dusky  red;  their  surface  is  smooth  and 
shining,  or  scaly,  eroded,  crusted  or  ulcerous;  their  consistence  is 


T UBERC ULO- ULCERA  TI VE  DERMA  TOSES 


257 


remarkably  soft,  compressible,  velvety;  they  are  easily  penetrated 
with  sharp  instruments;  they  are  often  tender  on  touch. 

When  a  lupus  tubercle  is  subjected  to  vitropressure  or  diascopy, 
to  drive  out  the  blood,  its  tissue  is  seen  through  the  glass  slide 
to  be  of  a  translucid  deep  yellow  color,  comparable  to  barley 
sugar  or  apple  jelly,  distinctly  outlined  from  the  creamy  white 
surface  presented  by  the  normal  derma.  This  pathognomonic 
transparency  of  the  compressed  lupoma,  which  is  due  to  the 
local  disappearance  of  the  elastic  and  connective-tissue  network 
(Fig.  89),  is  easily  distinguished  from  the  opaque  coloration  shown 
under  the  same  conditions  by  a  pigmentary  spot  or  a  soft  verrucous 
nevus. 

b 


f  ,-.:v-    ■    •■%-'• 


Fig.  89.— Histology  of  lupus  tubercle.  Nodular  lupoma  of  the  cheek.  Stained 
with  acid  orcein  and  polychrome  blue.  The  tuberculous  newgrowth  occupies 
the  entire  thickness  of  the  derma  and  results  from  an  agglomeration  of  tubercles 
such   as  those  seen  in    Fig.    93.    a,    collection  of  epithelioid  cells;    b,  giant  cells; 

c,  infiltrate  of  lymphocytes  and  plasmocytes   forming  a  finely  granular  network; 

d,  d,  elastic  and  connective-tissue  framework  of  the  derma,  plainly  seen  to  be  inter- 
rupted at  the  level  of  the  tubercle  (accounting  for  the  softness  and  transparency  of  the 
latter) ;  e,  tense  thin  epidermis  almost  eroded  on  the  surface  of  the  lupoma;  /,  /,  rows 
of  lupous  infiltration,  seen  extending  into  the  hypoderm  or  (/')  around  a  hair 
follicle.      X  15. 

Lupoma,  as  a  rule,  has  a  tendency  to  persist  indefinitely,  gradu- 
ally extending  at  its  periphery  and  becoming  confluent  with  neigh- 
boring lesions.  The  duration  of  its  course  extends  over  months, 
years  or  decades.  However,  even  in  the  absence  of  all  therapeutic 
intervention,  two  contingencies  may  arise: 

Some  cases,  so-called  resolving  lupus,  will  heal  spontaneously 
and  become  cicatrized,  the  interstitial  sclerosis  more  or  less 
completely  strangling  and  extinguishing  the  cellular  newforma- 
17 


258     TUBERCLES  AND  TUBERCULO-ULCERATIVE  DERMATOSES 

tion.  This  spontaneous  cicatrization  usually  takes  place  in 
the  center  of  the  patch,  while  the  border  continues  to  proliferate 
(Fig.  168);  lupomas  are  often  seen  to  persist  or  reappear  in  the 
cicatrix,  which  is  smooth,  white,  pearly  and  more  or  less  flexible. 
This  last-named  fact  is  of  positive  diagnostic  value  in  the  differen- 
tiation from  circinate  and  serpiginous  syphilides.  The  treatment 
of  lupus  by  scarification,  punctate  cauterization,  light-  and  radium- 
therapy,  etc.,  aims  at  stimulating  and  favoring  the  process  of 
cicatrization,  which  is  the  natural  mode  of  cure. 

On  the  other  hand,  the  lupoma  may  undergo  necrosis  and  ulcera- 
tion. The  tendency  to  central  necrosis  which  belongs  to  all  processes 
caused  by  the  tubercle  bacillus  is  relatively  much  less  marked  in 
lupus  than  in  the  other  forms  of  cutaneous  tuberculosis.  In  some 
cases,  however,  it  may  become  more  pronounced,  giving  rise  to 
restricted,  rarely  extensive  or  even  enormous  destruction  of  tissue; 
the  latter  being  characteristic  of  lupus  exedens  and  vorax.  The 
features  of  lupus  ulcerations  will  be  discussed  elsewhere  in  this  book. 

Tubercles  of  Leprosy. — The  tubercles  of  leprosy,  or  lepromas, 
originate  either  on  erythematous  pigmented  spots  or  on  the  healthy 
skin.  They  may  appear  separately  and  insidiously,  or  in  crops 
of  numerous  lesions,  distributed  with  a  certain  symmetry  on  the 
face  !  Fig.  175),  on  the  limbs,  or  in  any  region  of  the  body. 

Their  usual  appearance  is  as  follows:  Their  size  varies  from 
that  of  a  hemp  seed  to  that  of  a  large  almond;  their  shape  is 
hemispherical;  their  elevation  is  variable;  the  color  is  a  dull  pink, 
or  purplish,  or  brownish;  their  surface  is  smooth,  always  hairless, 
sometimes  oily  or  scaly;  their  consistence  is  firm  at  the  onset,  but 
rather  sottish  and  shrunken  often  after  the  lapse  of  some  time. 

Their  principal  properties  are:  (1)  They  are  almost  invariably 
anesthetic  toward  pricks  or  burns,  sometimes  after  a  temporary 
stage  of  hyperesthesia;  (2)  they  are  histologically  composed  of 
collections  of  lepra  cells,  teeming  with  Hansen's  bacilli. 

Lepromas  may  become  confluent  in  lobulated  tumors,  or  they 
may  spread  out  in  patches  of  variable  extent,  moderately  promi- 
nent, with  a  smooth  or  irregular  surface  interspersed  with  telan- 
giectases, etc.;  when  they  occur  in  patches  they  are  designated  as 
leprous  infiltrations  or  surface  lepromas. 

The  duration  of  leprosy  tubercles  is  usually  very  long,  but  follows 
no  rule.  They  may  disappear  through  absorption,  leaving  a 
white  or  pigmented  cicatrix;  this  scar  of  leprosy  infiltrations  bears 
the  name  of  leprous  morphea. 

They  may  also  undergo  suppuration  and  ulceration;  a  primarily 
superficial  erosion  increasing  in  depth  and  growing  into  an  irregular 
deeply  excavated  ulcer,  with  swollen  margins,  and  a  sanious  floor, 
sometimes  becoming  phagedenic  and  mutilating. 


TUBERCULO-ULCERATIVE  DERMATOSES  259 

Lepromata  are  characteristic  of  the  tubercular  or  generalized 
cutaneous  form  of  leprosy  and  are  also  encountered  in  the  mixed 
form  (Chapter  XXVII). 

Local  treatment  of  leprosy  tubercles  yields  very  satisfactory 
results.  They  may  be  treated  with  salves  or  plasters  containing 
strong  reducing  agents,  or  preferably  by  cauterization  with  the 
galvanocautery,  which  leads  to  their  prompt  subsidence.  [High- 
frequency  and  radiotherapy  are  valuable  measures,  but  it  need 
hardly  be  said  that  local  treatment  of  a  few  nodules  has  little  or 
no  effect  on  the  course  of  the  disease.] 

Cutaneous  Sarcoids  or  Lupoids. — The  eruption,  which  was  first 
described  by  Boeck  (1899)  under  the  name  of  multiple  benign  cuta- 
neous sarcoid,  then  as  benign  lupoid,  manifests  itself  in  the  form  of 
lenticular  or  larger  tubercles,  which  never  become  ulcerated. 

General  remarks  on  the  sarcoids  will  be  found  further  on  and  are 
applicable  to  the  lupoids,  which  in  the  main  represent  merely  a 
superficial  dermic  type  of  sarcoid,  with  lesions  of  small  dimensions, 
affecting  more  particularly  the  face  and  the  upper  limbs. 

A  distinction  is  made  between  two  principal  forms: 

1.  Disseminated  Miliary  Lupoid. — The  eruption  consists  of  hemi- 
spherical elevations,  the  size  of  a  millet  seed  to  that  of  a  large  pea, 
of  a  pinkish,  then  livid  and  finally  brownish  color,  with  a  smooth 
or  very  slightly  scaly  surface,  of  semi-solid  consistence.  On  vitro- 
pressure  (compression  under  a  glass  slide)  their- tissue  is  less  trans- 
parent than  that  of  a  lupoma  and  often  seems  to  be  made  up  of 
separate  granules. 

The  eruption  is  symmetrical  and  situated  on  the  face,  the 
shoulders,  the  wrists  (Fig.  90)  and  in  general  on  the  extensor  sur- 
face of  the  upper  limbs;  more  rarely,  lesions  are  noted  on  the  scalp, 
the  back,  or  the  lower  limbs.  It  comes  on  in  a  few  weeks,  but 
increases  during  months  and  years  through  growth  and  multipli- 
cation of  the  lesions.  In  the  course  of  time,  the  latter  become 
flattened,  spreading  out  in  nummular,  sometimes  marginated,  spots 
and  finally  become  obliterated,  leaving  an  atrophic  often  not  very 
noticeable  cicatrix.  The  lesions  are  accordingly  tubercles,  in  the 
dermatological  sense  of  the  term.  They  never  ulcerate,  in  notable 
contradistinction  to  the  lesions  of  acnitis. 

The  duration  of  the  disease  when  left  to  itself  is  very  variable, 
from  five  to  ten  years  or  longer.  It  is  observed  much  more  fre- 
quently in  women,  between  the  ages  of  fifteen  and  forty  years,  than 
in  men.  The  lymphatic  glands  are  sometimes  enlarged.  In  a 
considerable  number  of  the  cases,  the  patients  are  evidently  suffer- 
ing from  glandular  or  visceral  tuberculosis. 

The  histology  of  lupoid  tubercles  is  characteristic.  The  derma 
is  found  to  contain  large  lobulated  or  branching  collections  formed 


260  T  UBERCLES  A  XD  T  UBERC  ULO-  ULCER  A  TI VE  DERMA  TOSES 

chiefly  of  epithelioid  cells,  lymphocytes  and  a  few  rare  giant  cells; 
these  collections  arc  separated  by  connective-tissue  strands,  in 
which  practically  no  trace  of  inflammation  is  demonstrable. 

Several  modes  of  treatment  have  proved  efficient,  notably  intra- 
muscular injections  of  calomel,  tuberculin  injections  and,  according 
to  Boeck,  arsenic  medication;  the  best  method  of  treatment  actually 
consists  in  combining  aovarsenobejizol  injections  with  tuberculin, 
injected  in  very  small  doses.  It  goes  without  saying  that  the 
hygienic  condition  of  the  patients  must  be  supervised. 


Fig.  90. — Disseminated  miliary  Lupoid.     Multiple  benign   cutaneous  sarcoid   of 
Boeck. 


2.  Nodular  Lupoid.  Nodular  lupoid  and  lupoid  in  patches 
(large  nodular  form  of  Boeck)  is  less  well  known.  It  consists  of 
hemispherical,  purplish  or  brownish  red  elevations,  the  average 
size  of  half  a  ha/el-nut,  or  in  other  cases  of  irregularly  outlined 
soft  disks;  these  lesions,  to  the  number  of  two  or  three  up  to  ten 
or  more,  occupy  the  forehead,  the  nose,  the  shoulders,  the  elbows, 
the  neighborhood  of  the  knees,  etc. 

Confusion  is  possible  with  lupus,  superficial  tubercular  syphilides, 


TUBERCULO-ULCERATIVE  DERMATOSES 


261 


or  leprosy  infiltration.  Their  histology  is  related  to  that  of  lupus, 
but  inoculation  of  their  tissue  into  guinea-pigs  does  not  produce 
tuberculosis.     The  tuberculin  reaction  is  not  constant. 

I  have  thought  that  these  two  forms  of  lupoid  which  1  have  seen 
coexisting  with  tuberculides  or  with  glandular  and  pulmonary 
tuberculosis,  were  tuberculides;  this  is  very  probable,  but  not 
certain.  Gorgen  Schaumann  (January,  1917)  interprets  the  condi- 
tion as  a  special  benign  infectious  lymphogranuloma,  of  the  same 
character  as  lupus  pernio. 

Granuloma  Annulare. — Undoubtedly  identical  with  the  ringed 
eruption  of  Colcott  Fox,  the  lichen  annularis  of  Galloway,  the 
sarcoid  tumors  of  Rasch,  the  nodular  and  circinate  neoplasias  of 
Brocq,  the  granuloma  annulare  of  Radciiffe  Crocker  is  characterized 


Fig.  91. — Granuloma  annulare.     The  patient,  a  girl  of  three  years,  presented  seven 
other  similar  lesions  upon  the  limbs. 


by  elevations  or  tubercles  grouped  in  rings.  At  the  onset,  a  firm, 
smooth  nodule  the  size  of  a  small  pea  develops  rather  rapidly;  by 
eccentric  growths,  or  by  accession  of  other  nodules,  this  becomes 
transformed  into  a  ring  (Fig.  91);  the  color  is  a  pale  or  dull  pink; 
there  is  absolute  painlessness.  The  course  is  very  slow,  lasting 
months  or  years ;  the  lesions  never  ulcerate  and  no  scar  is  left  after 
healing. 

This  affection,  which  is  rare,  is  observed  in  children  or  adults 
of  both  sexes  and  occupies  more  particularly  the  hands,  the  finger- 
joints  and  the  wrists  as  well  as  the  ankles,  but  also  the  elbows, 
the  knees,  the  buttocks,  the  nape  of  the  neck,  exceptionally  the 
face.  As  a  rule,  the  lesions  are  few  in  number.  Histology  shows 
a  perivascular  infiltration  of  lymphoid  and  epitheloid  cells,  deeply 
situated  in  the  corium;  the  epidermis  is  intact. 


202     TUBERCLES  AND  TUBERCULO-ULCERATIYE  DERMATOSES 

Granuloma  annulare  in  many  respects  approximates  the  sarcoids 
and  the  lupoids.  Graham  Little,  in  his  very  complete  study  of 
the  subject  (1908)  is  inclined  to  consider  it  as  a  tuberculide.  It  is 
treated  with  reducing  plasters  and  the  same  general  medication  as 
the  sarcoids. 

The  erythema  elevatum  diuHnum  of  R.  Crocker  is  probably  merely 
;i  disseminated  or  grouped  but  not  annular  variety  of  the  same 
affection. 


CHAPTER  XIV. 
NODES  AND  NODULES. 

NODULAR  DERMATOSES. 

Under  the  name  of  nodes  I  comprise  all  circumscribed  indurations 
of  the  hypoderm,  of  whatever  character.  Nodes  may  attain  the 
size  of  an  egg,  or  larger;  nodules  in  my  nomenclature  are  those 
having  the  average  size  of  a  pea;  nodosities  are  those  having  inter- 
mediate dimensions. 

Nodes  constitute  an  elementary  dermatological  form,  a  symptom 
comparable  to  an  eruptive  lesion.  They  play  a  part  which  must  not 
be  underrated  in  the  pathology  of  the  skin.  In  my  opinion,  they 
must  of  necessity  figure  in  the  morphology  of  the  dermatoses. 

The  hyperderm  is  closely  related  to  the  corium  by  the  continuity 
of  the  connective-tissue  and  elastic  fibers  passing  from  one  to  the 
other  as  well  as  by  its  blood  and  lymph  vessels;  furthermore,  the 
bulbs  of  the  largest  hairs  and  the  glomeruli  of  the  large  sweat  glands 
are  imbedded  in  the  hypoderm. 

On  account  of  this  inter-relation  of  tissues  and  vascular  supply, 
pathological  processes  are  very  apt  to  invade  the  two  layers  together 
or  successively,  so  that  many  pathological  products  are  dermo- 
hypodermic. 

The  group  of  nodes,  formerly  designated  as  phyma  (French: 
noudures;  German:  Knollen  [or  Knoten]),  is  usually  subdivided  in 
France  and  classed  in  part  under  subcutaneous  tubercles,  in  part 
with  gummas  or  even  with  tumors,  etc. 

It  seems  to  me  advantageous  to  devote  a  special  chapter  to  their 
discussion. 

Nodes  or  nodosities  may  be  subdivided  according  [1]  to  then- 
volume,  their  consistence,  their  more  or  less  distinct  limitation;  but 
the  diagnostic  value  of  these  features  is  insignificant;  [2]  according  to 
their  purely  hypodermic  or  dermo-hyper dermic  seat,  but  this  seat 
may  vary  in  the  course  of  their  development;  [3]  according  to  their 
inflammatory,  embolic,  or  neoplastic  pathogenesis;  this  is  not  easy 
to  determine  clinically.  It  is  preferable  to  base  a  classification  on 
their  course. 

From  this  viewpoint,  three  forms  can  be  distinguished: 

A.  Acute  nodes  and  nodosities  of  sudden  onset,  are  of  ephemeral 
or  not  very  prolonged  duration,  from  one  to  fifteen  days,  for  instance, 
and  always  terminate  by  resolution,  without  suppuration. 


264  NODES  AND  NODULES 

In  tliis  acute  form,  the  size  of  the  products  varies  from  that  of  a 
pea  to  that  of  a  hen's  egg;  their  consistence  is  resistant  or  edematous; 
their  boundaries  arc  indistinct,  in  the  sense  of  their  occupying 
simultaneously  the  subcutis  and  the  cutis,  with  somewhat  diffuse 
outlines;  the  skin  is  usually  congested  on  their  surface;  they  are 
painful  to  touch.  Their  abrupt  appearance,  in  certain  regions  of 
predilection,  their  distinctly  inflammatory  character,  their  tendency 
to  resolution  are  suggestive  of  their  resulting  from  septic  emboli  of 
low  virulence. 

Among  the  dermatoses  in  which  acute  nodes  are  met  with,  I  shall 
describe  erythema  nodosum  and  rheumatic  nodosities.  Giant  urticaria 
might  likewise  figure  in  this  connection. 

B.  Subacute  nodes  and  nodosities  develop  insidiously  and  last 
from  a  fortnight  to  several  months,  or  even  a  number  of  years. 
Their  volume  usually  varies  from  that  of  a  hazel-nut  to  that  of  a 
green  almond;  their  consistence  and  the  appearance  of  the  skin  are 
modified  according  to  their  course  of  development;  they  are  only 
slightly  painful.  Their  pathological  anatomy  shows  them  to  be 
derived  from  a  subacute  inflammatory  process,  frequently  having  a 
venous  or  arterial  point  of  origin  and  generally  of  specific  character. 
These  cases  accordingly  represent  syphilitic,  tuberculous,  leprous, 
mycotic,  or  analogous  newformations. 

In  this  subacute  form  it  is  necessary  to  distinguish  a  group  of 
nodosities  with  a  well-marked  tendency  to  softening  and  ulceration: 
these  are  designated  as  gummas.1 

Under  the  name  of  gummas  will  be  accordingly  discussed,  first 
in  order:  Syphilitic  gummas,  tuberculous  gummas  and  finally  mycotic 
gummas,  a  more  recent  addition  to  our  knowledge. 

Another  paragraph  will  be  devoted  to  a  discussion  of  subacute 
non-gummous  nodes.  Their  course  and  duration  are  very  variable; 
some  of  them  never  become  softened  and  ulcerated,  others  excep- 
tionally so.  Under  this  heading  I  group:  the  nodular  syph  Hides, 
the  sarcoids,  which  are  probably  hypodermic  tuberculides,  and  the 
hypodermic  lepromas. 

C.  If  it  were  desirable  to  establish  a  group  of  chronic  nodes  or 
nodosities,  persisting  indefinitely,  one  might  do  so  at  the  expense 
of  the  hypodermic  tumors,  which  exist  in  all  varieties  of  size  and 
consistence.  Among  such  tumors  as  are  sometimes  capable  of 
giving  rise  to  serious  diagnostic  difficulties,  the  following  may  be 
mentioned. 

Certain  subcutaneous  hard  fibromas;  many  molluscoid  nevi  and 
fibroma  molluscum,  such  as  those  of  Kecklinghausen's  disease;  a 

1  The  student's  attention  must  be  called  to  the  fact  that  the  French  employ  the 
term  Gomme  (gumma)  in  a  wider  sense  than  is  customary  in  English.  The  sig- 
nificance of  the  term  i«  obvious  from  the  text. 


ACUTE  NODULAR  DERMATOSES  265 

considerable  number  of  cysts;  a  few  deep  epitheliomas,  cylindromas 
and  metastatic  carcinomas;  lipomas,  myomas,  calcareous  tumors, 
deep  angiomas  and  many  sarcomas  (Chapter  XXXI). 

ACUTE  NODULAR  DERMATOSES. 

Erythema  Nodosum. — This  affection  is  usually  considered  as  a 
simple  variety  of  polymorphous  erythema;  but  it  certainly  represents 
the  most  individualized  type  of  the  disease. 

Erythema  nodosum  is  characterized  by  an  eruption  of  nodosities 
or  nodes,  dermo-hypodermic  from  the  start,  rounded  or  oval, 
from  the  size  of  a  bean  to  that  of  a  large  nut,  of  pinkish,  carmine- 
red  or  purple  color,  rather  prominent,  not  very  distinctly  outlined, 
painful  to  touch.  They  appear  in  a  few  hours,  often  with  general 
disturbances  consisting  of  fever,  malaise,  prostration,  rheumatoid 
pains  or  actual  arthritides;  their  number  varies  from  a  few  lesions 
to  about  thirty;  they  are  found  scattered,  more  rarely  arranged  in 
groups  on  both  legs,  on  the  back  of  the  feet,  the  thighs  and  sometimes 
on  the  forearms,  the  arms  and  the  buttocks.  The  bluish  color  of  the 
lesions,  which  often  does  not  disappear  on  pressure,  is  due  to  inter- 
stitial hemorrhage ;  it  undergoes  the  color  variation  of  blood  in  course 
of  absorption  and  has  given  the  name  of  contusiform  dermatitis  to 
this  affection. 

The  topographical  distribution  of  the  eruption,  which  is  practically 
always  chiefly  localized  on  the  legs,  its  spontaneous  onset,  its  course 
and  its  duration  which  as  a  rule  does  not  exceed  two  or  three  weeks, 
permit  it  to  be  easily  distinguished  from  traumatic  contusions, 
gummas,  sarcomas,  etc. 

The  etiology  of  this  eruption  agrees  in  indefiniteness  with 
that  of  polymorphous  erythema;  sometimes  it  becomes  associated, 
moreover,  with  other  manifestations  of  this  erythema.  It  may  be 
observed  in  the  course  of  septicemias  or  toxicodermias,  notably 
in  iodism.  Its  frequency  has  been  commented  upon  in  venereal 
clinics,  among  patients  suffering  from  gonorrhea  or  syphilis. 
Mauriac  and  others,  without  sufficient  reason,  have  actually  admitted 
the  existence  of  a  syphilitic  erythema  nodosum.  Formerly,  all 
nodular  erythemas  were  regarded  as  rheumatic.  There  is  now  a 
tendency  to  hold  tuberculosis  especially  responsible;  in  support  of 
this  association,  the  practically  general  significance  of  which  he  had 
asserted  since  1907,  Landouzy  recently  reported  a  case  in  which, 
with  his  collaborators,  he  discovered  a  Koch's  bacillus  in  a  blood- 
vessel and  successfully  tuberculized  a  guinea-pig  with  a  portion  of 
the  same  nodule  removed  for  biopsy. 

The  pathological  anatomy  of  the  nodes  of  erythema  reveals  an 
acute  inflammation  of   ordinary  type,  with  extravasation  of  red 


206  NODES  AND  NODULES 

corpuscles  and  a  perivascular  infiltration  of  round  cells  between 
the  adipose  lobules;  these  lesions  necessarily  suggest  an  origin  from 
microbic  emboli,  placing  them  in  the  class  of  "phlebitides  of  the 
cutaneous  veins,"  studied  by  Philippson.  Although  it  seems  to  be 
an  established  fact  that  a  transitory  tubercular  bacillemia  is 
responsible  in  a  certain  number  of  cases  of  nodular  erythema,  it 
must  not  be  overlooked  that  the  immediate  prognosis  of  this 
affection  is  in  the  main  always  favorable  and  that  the  prognostic 
significance  of  this  blood  infection  must  not  be  overrated. 

The  treatment  is  that  of  polymorphous  erythema;  rest  is  especially 
necessary. 

Rheumatic  Nodosities. — The  nodosities  known  under  this  name 
must  be  approximated  to  erythema  nodosum.  Several  types  have 
been  described,  all  equally  uncommon.  In  some  arthritics  suffering 
from  subacute  rheumatism  and  intestinal  dyspepsia ,  I  have  observed 
the  appearance  of  crops  of  nodules  the  size  of  a  pea,  subcutaneous 
and  without  change  of  color  of  the  skin,  or  intradermic  and  rose- 
colored,  of  firm  consistence,  very  painful  on  palpation.  They  were 
situated  especially  around  the  knees,  at  the  wrists,  the  shoulders, 
etc.,  and  lasted  from  twenty-four  to  forty-eight  hours. 

Fereol  observed  non-erythematous,  very  transitory,  painless 
nodosities,  adherent  to  the  skin,  located  especially  on  the  forehead, 
but  always  in  small  numbers. 

The  type  pointed  out  by  Meynet  concerned  deeply  adherent, 
hard,  elastic,  or  edematous  subcutaneous  nodosities,  without 
reddening  of  the  skin  and  slightly  painful.  Their  volume  varies  from 
that  of  a  pea  to  that  of  a  walnut.  The  crops  consist  of  a  fairly 
considerable  number  of  lesions,  situated  especially  over  bony  pro- 
tuberances, more  particularly  on  the  skull.  Their  duration  is  from 
a  few  days  to  several  weeks.  Confusion  must  be  guarded  against 
with  gummas  or  with  tumors. 

Possibly  these  clinical  forms  are  varieties  of  the  same  species, 
but  it  is  more  probable  that  this  syndrome  expresses  the  result  of 
benign  microbic  embolisms  of  variable  character. 

The  treatment  consists  in  the  administration  of  salicylates  and 
calcium  salts. 

GUMMAS. 

Gummas  are  nodular  pathological  products,  of  infectious  character 
and  subacute  behavior,  the  course  of  which  comprises  four  stages: 
(1)  Development;  (2)  softening;  (3)  ulceration  and  evacuation; 
(4)  repair.  They  are  situated  in  the  subcutis,  where  they  originate 
primarily  around  the  blood  and  lymph  vessels  of  this  tissue;  some- 
times, they  may  reach  it  secondarily  to  a  process  of  the  same  char- 
acter developing  in  a  subjacent  organ,  periosteum,  gland,  etc. 


GUMMAS  267 

Many  authors,  who  regard  the  essential  feature  of  a  gumma  as 
consisting  of  its  special  evolution,  rather  than  of  its  hypodermic 
seat,  describe  dermic  gummas,  developing  in  the  cutis;  this  term  is 
interchangeable  with  tubercles.  All  that  need  be  said  is  that 
tubercles  occasionally  follow  an  evolution  like  that  of  gummas. 

Hypodermic  gummas,  or  true  gummas,  which  are  alone  discussed 
here,  are  syphilitic,  tuberculous,  or  mycotic. 

Syphilitic  Gummas. — These  represent  typical  lesions  of  this 
group.  The  gumma  begins  as  a  limited  induration  of  the  hypoderm, 
perceptible  to  the  touch  before  it  becomes  visible;  it  gradually 
enlarges,  setting  up  around  it  an  inflammatory  reaction,  first  raises 
and  then  invades  the  derma  and  finally  almost  invariably  opens 
externally  through  a  crater-shaped  ulceration. 

In  the  developed  stage,  the  nodule  is  of  firm  consistence,  the  size 
of  a  pea  to  that  of  a  walnut,  indolent  and  movable.  The  mass 
becomes  pasty,  then  fluctuating,  superficially  and  sometimes  deeply 
adherent;  the  skin  becomes  reddened  and  thinned.  Up  to  this  time, 
absorption  may  occur  without  leaving  a  cicatrix,  both  spontaneously 
and  especially  with  the  help  of  specific  treatment. 

More  frequently  the  skin,  raised  and  eroded  from  below,  becomes 
perforated  on  top  of  the  protuberance;  ulceration  occurs  and  leads 
to  the  escape  of  a  turbid  or  purulent  yellowish  ropy  [gummy]  fluid. 
The  orifice  enlarges,  remaining  round,  of  nummular  dimensions; 
its  borders  are  thin,  red,  overhanging  or  perpendicular;  the  cavity 
is  deep,  cup-shaped ;  the  floor  is  uneven,  roughened,  covered  with  a 
yellowish-white  substance,  a  sort  of  core,  which  is  gradually  elimi- 
nated with  the  discharge;  the  base  is  of  pasty  consistence  and  tender 
on  pressure.    The  corresponding  lymph  nodes  are  not  enlarged. 

In  the  stage  of  retrogression,  the  granulating  floor  becomes  raised 
to  the  level  of  the  borders  where  epidermatization  begins,  concen- 
trically retracting  and  finally  cicatrizing  the  ulcer  after  the  infiltra- 
tion has  disappeared.  The  redness  is  replaced  by  a  persistent 
pigmentation  which  surrounds  the  white  and  smooth  cicatrix. 

This  evolution  extends  over  a  space  of  time  from  fifteen  to  forty- 
five  days. 

Syphilitic  gummas  are  tertiary  manifestations.  Sometimes  they 
are  precocious,  appearing  in  the  second  half-year  after  infection, 
and  in  this  case  they  are  called  secondo-tertiary,  according  to  Four- 
nier's  expression.  Although  especially  frequent  in  the  third  and 
fourth  year,  they  may  still  occur  after  ten  or  fifteen  years  or 
more. 

They  may  be  situated  anywhere,  rather  commonly  on  the  forehead, 
on  the  scalp,  at  the  lips,  the  genitals;  they  are  often  multiple  or 
develop  in  close  succession  to  the  number  of  from  two  to  ten  or 
thereabouts,  rarely  more. 


2G8  NODES  AND  NODULES 

Gummas  of  the  tongue  are  rather  rare.  They  appear  in  the  form  of 
one  or  several  hard  intramuscular  nodes  the  size  of  cherry  pits  on 
hazel-nuts,  studding  the  tongue  and  causing  more  inconvenience 
than  actual  pain.  They  open  as  large  ampullary  or  crater-shaped 
ulcers,  which  heal  leaving  a  very  minute  cicatrix.  It  is  important 
to  distinguish  them  from  the  sclero-gummous  ulcer*. 

Gumma.'!  of  the  palatine  velum  are  rarely  discovered  before  they 
ulcerate.  They  give  rise  to  merely  slight  inconvenience  during  a 
week  or  two,  then  perforation  of  the  palate  suddenly  occurs  without 
pain,  often  during  a  meal,  manifesting  itself  by  the  return  of  liquids 
through  the  nasal  fossa1  and  by  nasal  speech.  The  gravity  of  this 
complication  is  due  to  these  functional  disturbances,  which  are 
persistent,  cicatrization  taking  place  without  closing  the  perforation. 
Recourse  must  be  had  to  a  [plastic]  operation  or  a  prosthetic  appa- 
ratus. Perforation  of  the  palatine  velum  has  long  been  considered 
as  a  reliable  stigma  of  syphilis  or  congenital  syphilis.  It  has  been 
reported  under  other  conditions,  notably  after  scarlatina  (?). 

In  the  treatment  of  gummas,  incision  of  the  swelling  has  no 
advantages  and  is  only  too  often  practised  erroneously.  Even 
total  excision,  with  careful  suturing  of  the  wound,  would  be 
preferable;  but  syphilitic  gummas,  even  after  softening  has  occurred, 
heal  as  a  rule  remarkedly  well  under  specific  treatment  in  all  its 
forms.  The  importance  which  was  formerly  attached  to  iodin 
in  the  treatment  of  gummas,  is  undoubtedly  due  to  the  confusion 
which  prevailed  between  syphilitic  gummas  and  those  now  known 
to  be  of  mycotic  character.  Very  dilute  local  injections  of  soluble 
mercurial  salts  are  very  efficient  and  may  be  utilized. 

Tuberculous  Gummas — also  known  as  scrofulo-tubercular  gummas, 
or  abroad  as  scrofuloderma — differ  from  the  preceding  by  a  few 
details  in  their  objective  appearance  and  by  their  more  gradual,  less 
continuous  evolution. 

The  hypodermic  nodosity  which  marks  the  onset  of  a  tuberculous 
gumma,  is  sometimes  adherent  from  the  start  to  the  deep  aspect 
of  the  derma,  which  rather  early  presents  a  lavender,  purplish,  or 
livid  hue.  Softening  often  begins  superficially  without  affecting  the 
entire  indurated  mass;  it  may  be  absent  or  indefinitely  delayed. 
The  fluid  is  sanious  or  even  serous,  turbid  and  mixed  with  blood. 
Ulceration  is  frequently  of  an  irregular  configuration,  with  soft, 
detached,  purplish  borders;  the  cavity  is  irregular,  sinuous,  some- 
times sending  fistulous  tracts  in  different  directions;  it  is  lined  with 
gray  or  purplish  filamentous  detritus;  its  walls  are  softened  or 
locally  indurated. 

It  is  not  uncommon  for  the  multiple  orifices  of  the  same  gumma, 
or  of  neighboring  gummas  united  in  a  gummous  infiltration,  to  inter- 
communicate by  sinuous  tracts  which  lead  into  the  same  cavity; 


GUMMAS  269 

they  are  separated  by  bridges  which  may  persist  even  after  cica- 
trization or  may  rupture  as  the  result  of  erosion. 

Tuberculous  gummous  ulcers  accordingly  often  have  sinuous  and 
ragged,  undermined,  pale  or  dark  purple  borders  and  an  extremely 
irregular  floor.  The  discharge  is  very  variable,  distinctly  purulent, 
or  serous  and  mixed  with  blood.  The  crusts  possess  corresponding 
features. 

These  ulcers  may  invade  the  tendon  sheaths,  the  joints  and  the 
bones,  from  which  they  may  also  be  derived.  They  are  sometimes 
transformed  into  fungoid  tuberculosis  or  lupus.  When  they  heal, 
the  cicatrix  is  usually  irregular,  often  adherent  in  the  depth  of  the 
tissue,  honey-combed  with  fibrous  islands,  dentated  at  the  periphery 
or  undermined  by  fistulous  tracts  which  pass  under  cicatricial 
bands.  The  borders  remain  for  a  long  time  purplish,  later  becoming 
pigmented. 

The  course  is  slow,  with  exacerbations  and  remissions,  lasting 
several  months  or  sometimes  years. 

Scrofulo-tubercular  gummas  are  frequently  but  not  invariably 
encountered  in  individuals  whose  general  condition  is  unfavorable, 
who  suffer  from  visceral  tuberculosis  or  especially  from  bony  or 
glandular  tuberculosis.  Children  and  youthful  individuals  are  the 
most  susceptible.  They  number  from  one  or  two  to  about  ten, 
rarely  more  lesions  presenting  different  stages;  they  occupy  espe- 
cially the  extremities  or  the  neck,  sometimes  the  trunk,  but  often 
the  face.  They  are  disseminated,  more  particularly  in  children 
and  youthful  individuals;  or  they  may  show  a  regional  distribu- 
tion, especially  when  they  are  consecutive  to  a  deep  focus  and, 
in  these  cases,  assume  a  lymphangitic  type. 

Tuberculous  gummous  lymphangitis,  practically  limited  to  the 
extremities,  originates  from  a  lesion  of  the  extremities,  usually  an 
anatomical  tubercle,  tuberculosis  verrucosa,  spina  ventosa,  or 
tuberculous  caries  of  the  bones.  Arranged  along  the  tract  of  the 
lymphatics  coming  from  this  primary  focus,  a  series  of  several 
gummas  begins  to  develop.  A  lymphatic  strand  may  occasionally 
be  felt  which  unites  these  secondary  foci.  The  corresponding 
glands  are  usually  indurated,  sometimes  suppurating  or  fistulized. 
The  duration  of  this  trouble  is  indefinite;  it  may  be  prolonged  until 
death  occurs  from  vertebral  or  visceral  tuberculosis  and  from 
cachexia. 

The  'pathological  anatomy  of  tuberculous  gummas  will  be  dis- 
cussed elsewhere  in  this  book.  It  will  be  seen  that  they  usually 
contain  Koch's  bacilli,  although  in  moderate  numbers,  and  that 
their  tissue  causes  tuberculosis  in  guinea-pigs  inoculated  with  it. 
However,  clinically  identical  products  are  also  met  with  whose 
scrapings  and  sections  contain  no  bacilli  and  whose  inoculation  into 


270  XODES  AND  NODULES 

animals  remains  negative.  This  justifies  the  conclusion  that  the 
clinical  picture  of  scrofulo-tuberculous  gumma  may  be  produced  by 
hypodermic  tuberculides. 

The  same  picture  may,  moreover,  be  very  closely  simulated  by 
mycotic  gummas;  a  thorough  examination  of  the  patient  in  regard 
to  his  antecedents  and  the  coexistence  of  internal  tuberculous  lesions, 
is  imperative  for  the  diagnosis,  although  in  many  cases  only  the 
laboratory  findings  are  capable  of  confirming  it. 

Mycotic  Gummas.- — Several  infections  through  fungi  may  give 
rise  to  genuine  gummas.  Sporotrichosis  is  the  best  known  of  these 
and  also  the  most  common.  Sporotrichotic  gummas  are  sometimes 
disseminated,  sometimes  lymphangitic  and  regionally  distributed. 
When  disseminated,  they  may  be  found  anywhere,  in  variable 
number;  they  are  indolent  and  develop  in  six  to  eight  weeks.  Firm 
at  first,  then  soft,  they  persist  for  more  or  less  time  in  this  condition, 
then  undergoing  ulceration  and  evacuation.  Their  liquid  contents 
are  at  first  viscid  and  gummous,  later  on  purulent  and  thickened. 
The  ulcer  may  be  covered  by  a  crust,  of  ecthymatous  appearance,  or 
again  very  deep,  of  rounded  or  irregular  circumference,  with  under- 
mined margins;  sometimes,  the  floor  is  covered  with  granulation  or 
even  large  proliferations.  This  ulcer  remains  stationary  a  long  time, 
unless  treatment  intervenes  (p.  605). 

Sporotrichotic  gummous  lymphangitis  consists  of  a  series  of 
gummas  developing  in  the  centripetal  lymphatic  territory  of  the 
initial  focus  (Fig.  ISO),  which  may  be  dermic  or  hypodermic,  or 
bony,  etc.  A  moniliform  strand  may  connect  the  lesions.  The 
corresponding  glands  are  often,  but  not  always  swollen  and 
enlarged. 

Actinomycosis,  in  its  primary  cutaneous  form,  often  has  the 
appearance  of  a  hypodermic  nodule,  with  a  pinkish  surface,  hard 
and  practically  painless,  which  softens  at  its  center  and  ulcerates, 
but  from  which  a  sanguinolent  discharge  escapes  instead  of  pus; 
the  orifice  remains  fistulous.  Neighboring  nodules  form  and  become 
agglomerated  with  the  first.  The  lymph  glands  remain  intact.  The 
site  of  the  lesions  is  most  commonly  the  cervico-facial  region  (p.  599). 

Some  blastomycoses  may  give  rise  to  gummas.  This  is  particularly 
true  for  the  Buschke  type,  of  which  a  few  rare  observations  have 
been  recorded;  it  is  a  febrile  infection,  seriously  interfering  with 
the  general  health.  The  origin,  as  a  rule,  is  in  the  osseous  system 
whence  there  follow  multiple  disseminated  gummas.  [It  would 
seem  probable  that  the  point  of  entry  for  the  organisms  is  an  insig- 
nificant cutaneous  lesion,  though  a  periosteal  swelling  may  be  the 
first  lesion  to  attract  attention]  (p.  603). 

Mycetoma,  or  Madura  foot,  is  a  local  mycosis  characterized  by 
nodosities  which  become  bullous  on  their  surface,  then  softened  and 


SUBACUTE  NON-GUMMOUS  NODES  271 

ulcerated,  accordingly  representing  true  gummas;  their  agglomera- 
tion may  result  in  a  monstrous  deformity. 

In  "picm-bois,"  a  Leishmaniosis,  I  have  observed  a  sort  of  gumma 
with  a  lymphangitic  distribution. 

For  the  diagnosis  and  treatment  of  these  mycotic  gummas,  the 
reader  is  referred  to  Chapter  XXVIII. 

[All  the  forms  of  cutaneous  and  subcutaneous  tuberculosis  are 
relatively  rare  in  America  and  blastomycosis  seems  to  be  more 
common  than  sporotrichosis  while  the  converse  is  true  in  France 
and  Germany.] 

-SUBACUTE  NON-GUMMOUS  NODES. 

Nodular  Syphilides. — This  name,  as  well  as  that  of  nodular 
syphilitic  phlebitis,  is  applied  to  hypodermic  nodules  which  some- 
times occur  in  the  course  of  the  secondary  manifestations  of  severe 
syphilis,  associated  in  most  cases  with  a  profuse  eruption  of  lentic- 
ular papules. 

The  nodules  are  hard,  distinctly  outlined,  movable  under  the  skin 
and  on  the  underlying  tissues,  round,  spindle-shaped  or  flattened, 
the  size  of  a  large  pea  to  that  of  an  almond ;  the  skin  on  their  surface 
is  normal  or  slightly  reddened.  They  are  painless  when  left  alone, 
but  slightly  tender  on  pressure.  They  are  situated  in  variable 
numbers,  from  a  dozen  to  twenty  at  most,  on  the  extremities,  rarely 
elsewhere. 

Their  size,  their  topography,  their  number,  their  free  mobility, 
and  especially  their  course,  serve  to  distinguish  them  from  the 
nodosities  of  erythema  nodosum  and  syphilitic  gummas. 

In  a  case,  observed  with  Civatte,  the  histological  examination 
enabled  us  to  recognize  distinctly  the  presence  of  a  syphilitic 
newformation  (of  the  same  type  as  the  lenticular  papule)  which 
developed  in  the  wall  of  the  subcutaneous  veins  giving  rise  to 
thrombophlebitis. 

The  evolution  of  these  nodular  phlebitides  is  rather  slow.  They 
have  practically  no  tendency  to  undergo  softening  and  ulceration, 
but  in  the  absence  of  treatment  will  persist  for  many  weeks  without 
change.  Under  the  influence  of  specific  treatment,  they  very 
promptly  disappear. 

Leprous  Nodosities. — These  products,  known  also  as  hypodermic 
lepromas,  often  accompany  the  dermic  leprous  tubercles  in  moderate 
number.  In  more  interesting  but  less  common  cases,  the  nodosities 
occur  without  tubercles,  coincidently  with  erythemato-pigmentary 
leprides.  They  can  be  detected  only  after  careful  search;  as  stated 
by  Leloir,  they  may  be  felt  rather  than  seen,  for  they  barely  raise 
the  skin, 


272  NODES  AXD  XODULES 

Hypodermic  lepromas  are  situated  chiefly  on  the  buttocks,  the 
back,  the  external  aspect  of  the  extremities,  on  the  face,  and  very 
frequently  on  the  ear-lobules,  which  appear  as  if  stuffed  with  shot. 

They  are  circumscribed,  rounded  or  oval,  the  size  of  a  pea  to  that 
of  a  walnut,  sometimes  conglomerated,  or  they  may  be  diffuse 
(leprous  infiltrations)  in  slightly  raised,  flat  or  uneven  patches. 

At  the  onset,  the  circumscribed  nodules  are  firm  and  elastic  and 
at  first  movable;  later  on  they  become  softened  and  adherent  to  the 
skin,  which  turns  red  on  the  surface.  Nodules  and  infiltrations 
may  ulcerate,  thus  becoming  entitled  to  the  name  of  leprous  gummas 
or  gummxms  infiltrations  of  leprosy;  they  contain  a  grumous  pus  very 
rich  in  Hansen's  bacilli.  They  often  seem  to  persist  indefinitely, 
or  they  undergo  absorption,  leaving  a  sclerotic  or  even  keloid 
cicatrix,  or  no  trace  of  their  former  presence. 


SARCOIDS. 

This  term  was  devised  by  Kaposi  to  designate  newformations 
resembling  sarcoma.  Boeck  (of  Christiania)  described  under  the 
name  of  multiple  benign  cutaneous  sarcoids,  eruptions  of  tubercles 
resembling  lupus;  more  recently,  he  called  them  lupoids.  Other 
newformations  have  also  been  designated  under  the  name  of 
sarcoids.  In  a  report  to  the  XVI  International  Medical  Congress 
(1909)  I  pointed  out  that  until  the  etiology  and  real  character  of 
these  new-formations  are  elucidated,  the  denomination  sarcoids  is 
indispensable. 

It  designates  a  group  of  connective-tissue  newgrowths  which 
manifest  themselves  clinically  in  the  form  of  nodes,  nodosities, 
nodules  or  tubercles,  usually  multiple,  painless,  of  slow  or  even 
chronic,  but  not  unlimited  development.  They  are  benign  in  the 
sense  that  they  have  no  tendency  toward  softening  and  ulceration, 
do  not  recur  locally  after  removal,  do  not  give  rise  to  visceral 
metastases  and  do  not  notably  affect  the  general  health.  They  are 
subject  to  retrogression,  either  spontaneously  or  under  the  influence 
of  arsenical  agents,  mercury,  tuberculin,  etc. 

Anatomically,  these  sarcoids  are  made  up  of  cellular  collections 
or  infiltrations  often  of  a  tuberculoid  structure,  insinuated  into  the 
framework  of  the  derma  or  the  hypoderm — which  distinguishes 
them  from  the  sarcomas,  whose  constituents  are  arranged  in  coherent 
and  homogeneous  masses. 

The  following  pathological  types  come  under  this  definition: 

1.  Cutaneous  Sarcoids. — Cutaneous  sarcoids  of  Boeck,  or  lupoids. 
Their  intradermic  seat  and  their  small  dimensions  have  led  me  to 
group  them  among  the  tubercles  (p.  2o9). 


SARCOIDS  273 

2.  Hypodermic  Sarcoids. — As  described  by  me  with  Roussy  (1904 
to  1906),  these  are  painless  subacute  or  chronic  newformations, 
the  size  of  a  bean  to  that  of  a  walnut,  or  larger;  they  often  become 
confluent  in  large  uneven  patches  and  nodular  strands.  The  skin 
over  them  is  raised,  of  normal,  lavender,  or  dull  red  color.  At 
first  sight,  they  might  be  mistaken  for  tumors,  but  they  have  no 
unlimited  extension.  They  are  observed  in  adults  of  both  sexes; 
their  duration  is  indefinite. 

These  sarcoids  are  generally  grouped  in  certain  regions,  and  have 
a  tendency  to  a  symmetrical  arrangement.  I  know  of  two  seats 
of  predilection:  on  the  one  hand,  the  costal  region,  the  flanks,  and 
the  scapular  region,  on  the  other,  the  anterior  aspect  of  the  thighs, 
and  the  lower  portion  of  the  abdomen.  However,  they  are  also  met 
with  elsewhere,  on  the  arms,  the  forearms  and  even  on  the  scalp. 
This  type  is  relatively  rare. 

These  sarcoids  must  not  be  confused  with  tumors  of  various  kinds 
of  the  thoracic  wall,  nor  with  axillary,  cervical  or  other  adenop- 
athies. On  the  thighs  they  may  be  very  closely  simulated  by 
nodosities  due  to  the  injection  of  camphorated  oil,  or  other  hypo- 
dermic injections,  which  sometimes  persist  indefinitely.  The 
appearance  of  genuine  sarcoids,  however,  seems  to  be  absolutely 
spontaneous.    The  paraffinomas  will  be  mentioned  further  on. 

3.  Disseminated  Nodular  Sarcoids. — These  are  nodes  or  nodules 
which  develop  successively  in  crops  and  are  scattered  particularly 
over  the  extensor  surface  of  the  extremities  more  or  less  symmet- 
rically, but  also  on  the  trunk  and  sometimes  even  on  the  face. 
They  usually  number  from  about  ten  to  thirty,  but  I  have  counted 
over  one  hundred  and  fifty  in  one  case  (Fig.  92).  The  skin  over 
them  is  of  normal  color,  or  pinkish,  or  brownish-purplish,  raised  or 
on  the  contrary  slightly  depressed  and  on  pressure  may  present  the 
appearance  of  orange-peel.  Their  consistence  is  very  hard,  or  some- 
what doughy;  with  rare  exceptions  they  are  painless.  Very  rarely, 
some  may  become  eroded  on  their  surface  and  covered  with  a  crust. 
They  are  observed  at  all  ages,  in  both  sexes,  and  are  not  very 
uncommon  [in  France].    They  may  disappear  spontaneously. 

These  disseminated  sarcoids  possess  a  great  analogy  with  scrof  ulo- 
tuberculous  gummas  in  the  firm  stage ;  they  differ  f  rOm  them  in  that 
they  do  not  soften  and  ulcerate;  but  these  two  pathological  types 
may  exist  together. 

They  also  possess  such  marked  analogies  with  the  erythema 
induratum  of  Bazin  that  I  have  thought  these  two  affections  might 
be  identical;  erythema  induratum  would  then  be  merely  a  particular 
form,  an  objective  appearance  of  disseminated  sarcoid.  It  is, 
however,  entitled  to  separate  mention. 

18 


274 


NODES  AND  XODULES 


4.  Erythema  Induratum  of  Bazin. — Under  the  name  of  crytheme 
indure  des  scrofuleux,  Bazin  had  described  more  or  less  deeply 
indurated  and  imperfectly  outlined,  pinkish,  red  orpnrplish  patches, 
which  are  observed  in  youthful  individuals,  especially  young  girls, 
almost  invariably  occupying  the  outer  and  lower  portion  of  the  legs; 
they  may  also  be  observed  on  the  thighs,  on  the  upper  limbs,  and 
even  on  the  forehead.  Their  course  is  subacute,  with  congestive 
exacerbations  accompanied  by  throbbing  pains;  periods  of  retro- 
gression occur  under  the  influence  of  rest. 


92. — Disseminated  nodular  sareoids  on  the 

aged  forty-five  years. 


lower  abdomen  of 


English  authors,  Colcott  Fox  and  especially  -I.  Hutchinson,  have 
shown  that  Bazin's  disease,  as  they  call  it,  not  infrequently  gives 
rise  to  sluggish  and  obstinate  ulcers  (Fig.  102);  this  is  the  English 
type,  or  Hutchinson's  type,  which  in  this  respect  distinctly  differs 
from  the  sarcoids  and  approximates  the  tuberculous  infiltrations. 

The  histological  structure  of  the  various  sarcoids  referred  to  above 
is  not  uniform.  The  structure  of  the  cutaneous  sarcoid  of  Boeck, 
or  lupoid,  is  entirely  distinct.  The  hypodermic  sarcoids  of  the 
1  )arier-Roussy  type  are  to  the  highest  degree  tuberculoi  1  in  structure 
(Fig.  93),  perfect  tubercles  [in  the  pathological  sense]  being  found 


SARCOIDS 


275 


in  addition  to  the  ordinary  lesions  due  to  reaction  of  the  adipose 
tissue,  known  since  Flemming  under  the  name  of  "  Wucheratrophie" 
(proliferative  atrophy).  The  disseminated  sarcoids  have  either 
an  analogous  structure,  or  that  of  inflammatory  newformations; 
the  whole  gamut  of  lesions  may  be  met  with  from  erythema  nodosum 
to  the  most  characteristic  tuberculous  gummas.  In  erythema 
nodosum,  the  infiltration  is  also  more  or  less  ordinary,  or  else  tuber- 
culoid with  partial  necrosis.  Thibierge  and  Ravaut,  Mantegazze 
and  Guibert  emphasize  the  vascular  lesions,  which  I  was  always 
able  to  demonstrate. 


Fig.  93. — Histology  of  hypodermic  sarcoids.  Tuberculoid  focus  at  the 
periphery  of  a  lobulated  nodosity  of  the  thoracic  region,  a,  giant  cell;  b,  zone  of 
epithelioid  cells;  c,  c,  zone  of  lymphocytes;  d,  fibrous  tissues  surrounding  the  nodosity ; 
e,  sclerosis  of  the  adipose  tissue;  g,  collection  of  epithelioid  cells  belonging  to  a  neigh- 
boring tubercle.      X  130. 


The  nature  of  the  sarcoids  is  obviously  infectious  and  the  patho- 
genic mechanism  of  their  origin  is  undoubtedly  through  embolism . 
But  their  etiological  connection  with  Koch's  bacillus,  which  would 
make  them  tuberculoses  or  tuberculides,  has  not  been  established, 
at  least  not  for  all  types.  Histology,  as  is  now  known,  does  not 
settle  the  question,  for  the  tubercle  is  by  no  means  characteristic 
of  the  bacillary  infection,  but  may  occur  in  the  mycoses,  in  syphilis, 
leprosy,  etc.  Inversely,  the  absence  of  tubercles,  according  to 
numerous  recent  contributions  in  no  way  excludes  the  presence  of 
Koch's  bacillus. 

As  regards  erythema  induratum,  its  tuberculous  nature  may  be 
said  to  be  an  established  fact  based  on  its  common  coincidence  with 
visceral,  bony,  glandular,  or  cutaneous  tuberculosis;  or  with  papulo- 


276  NODES  AND  NODULES 

neurotic  tuberculides  and  lichen  scrofulosorum ;  and  from  its  reaction 
to  tuberculin.  Still  more  direct  proofs  have  been  furnished;  its 
tissue  infects  inoculated  guinea-pigs  with  tuberculosis  (Thibierge 
and  Ravaut,  Carle)  and,  in  a  few  cases,  the  bacillus  has  been 
demonstrated  therein  (Philippson,  Jadassohn). 

Notwithstanding  coincidences  and  transition  forms,  no  such 
definite  conclusions  can  be  formulated  in  regard  to  the  other  types. 
It  is  still  desirable,  in  cases  coming  under  observation,  to  look  for 
the  Wassermann  reaction,  which  is  negative  as  a  rule,  and  for  the 
tuberculin  reaction  which  is  generally  positive,  as  well  as  to  carry 
out  the  necessary  laboratory  tests.  The  solution  of  this  problem 
belongs  to  the  future. 

The  treatment  of  sarcoids  with  arsenic  has  been  vaunted  as 
well-nigh  specific;  arsenobenzol  is  sometimes  remarkably  successful 
(Ravaut);  I  have  obtained  excellent  results  from  calomel  injec- 
tions; at  the  same  time  as  Thibierge,  I  became  impressed  with 
the  rapid  efficacy  of  tuberculin  injections  in  very  minute  doses, 
especially  in  erythema  induratum;  as  a  rule,  a  combined  medication 
with  novarsenobenzol  and  tuberculin  gives  the  best  results.  Rest 
and  good  general  hygiene  are  imperative.  In  spite  of  treatment, 
recurrences  are  to  be  anticipated. 

The  term  paraffinoma  has  been  applied  to  hypodermic  lesions 
which  are  often  caused  by  injections  of  paraffin;  in  certain  respects, 
these  may  be  compared  with  artificial  or  induced  sarcoids.  About 
fifteen  years  ago  vaselin  injections  and  then  injections  of  paraffin  at 
a  melting  point  of  65°  or  .V)°  were  recommended  for  the  correction 
of  various  congenital  or  acquired  deformities,  saddle-nose,  mis- 
shapen ears,  atrophic  rhinitis  with  ozena,  bad  sears,  fistulas,  and 
even  for  the  esthetic  improvement  of  the  face,  the  base  of  the  neck 
or  the  female  breast. 

These  injections  are  not  devoid  of  danger.  After  a  few  years,  a 
progressive  swelling  with  a  coppery  redness  and  very  painful  tension 
may  make  its  appearance  at  the  injected  points.  Its  cause  is  easily 
recognized  from  the  site  and  the  statements  of  the  patient. 

Histological  examination  shows  a  diffuse,  nodular,  chronic  inflam- 
mation, with  microscopical  abscisses  and  giant  cells,  caused  by  the 
paraffin  which  has  spread  between  the  tissue-meshes  and  hollowed 
out  cavities  lined  with  endothelium.  Injections  of  vaselin  or  cam- 
phorated oil  sometimes  produce  analogous  lesions.  Massage, 
electrolysis  and  aspiration  are  usually  inefficient  and  it  is  necessarv 
to  resort  to  surgical  ablation. 


CHAPTER  XV. 

ULCERATIONS,  ULCERATIVE  DERMATOSES  AND 
CUTANEOUS  GANGRENES. 

Ulcerations  of  the  skin  are  losses  of  substance  due  to  a  patho- 
logical process  of  molecular  destruction  or  of  gangrene,  in  contra- 
distinction to  wounds,  which  are  directly  produced  by  a  trauma. 

The  term  ulcer  is  reserved  more  particularly  for  chronic  ulcera- 
tions with  a  marked  tendency  to  persist  a  long  time  or  indefinitely. 

Cutaneous  gangrene  is  the  mortification  or  necrosis  of  a  more  or 
less  extensive  portion  of  the  tissues. 

I  shall  first  discuss  ulcerations  in  general  and  the  ulcerative 
process;  then  the  ulcerative  dermatoses;  finally,  gangrene. 

ULCERATION  IN  GENERAL. 

Clinical  Features. — The  various  ulcerations  are  differentiated  by 
numerous  features,  which  must  be  kept  in  mind  for  the  diagnosis. 

1.  The  variable  depth  of  the  loss  of  substance  permits  a  distinc- 
tion between :  excoriations,  which  are  superficial,  involving  only  the 
epidermis  and  often  resulting  from  a  blister,  a  superficial  pustule, 
or  a  vesicular  process;  they  heal  without  a  scar,  leaving  a  simple 
pigmentary  macule;  and  true  or  dermic  ulcerations,  which  encroach 
upon  or  destroy  the  derma  and  are  necessarily  followed  by  scar- 
formation. 

2.  The  extent  of  the  ulcerations  is  rarely  of  much  importance;  it 
is  useful  to  know,  however,  that  certain  varieties  never  acquire  large 
dimensions,  whereas  others  on  the  contrary  may  be  of  almost 
indefinite  extent. 

3.  The  configuration  is  geometrical  or  irregular,  rounded,  oval, 
polycyclic,  reniform,  circinate,  etc. 

4.  The  borders  may  be  either  sharp  or  imperfectly  outlined, 
perpendicular,  detached  or  overhanging,  sloping,  raised  or  flat, 
slanting,  everted,  fissured,  etc. 

5.  The  floor  may  be  level  or  uneven,  granular,  papillomatous, 
"worm-eaten,"  sinuous,  crateriform,  raised,  etc. 

6.  The  color  of  the  floor  of  ulcerations  is  red,  purplish,  grayish  or 
yellowish. 

7.  The  discharge  is  serous,  purulent,  hemorrhagic  or  sanious, 
and  more  or  less  profuse. 


278 


ULCERATIONS  AND   ULCERATIVE  DERMATOSES 


8.  The  crusts  which  resull  from  the  drying  of  the  exudate  present 
a  variable  appearance.  Ostreaceous  crusts,  which  arc  thicker  in 
the  center  and  apparently  made  up  of  heaped  up  disks  of  dimin- 
ishing size,  deserve  special  mention.  They  are  characteristic  of 
the  lesion  described  as  rupia  by  older  writers  (Fig.  94).  Their 
occurrence  is  noted  on  ulcerations  which  increase  intermittently, 
such  as  certain  syphilides,  more  rarely  in  ecthyma. 

9.  The  base  of  the  ulcerations  is  sometime-  soft,  edematous,  in 
other  cases  infiltrated  and  more  or  less  indurated. 

10.  The  periphery  varies  in  color,  consistence,  condition  of  its 
surface,  etc. 

11.  Tenderness,  spontaneous  or  induced,  or  on  the  contrary 
anesthesia,  are  peculiar  to  certain  form-. 


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12.  The  condition  of  the  corresponding  glands  deserves  attention; 
so  also    13)  the  site  and  (14)  the  course  of  the  ulcerations. 

Among  these  various  features,  those  relating  to  the  borders,  the 
configuration,  the  base  and  the  periphery  possess  the  greatest  value. 
They  may  afford  information,  to  a  certain  degree  at  least,  as  to  the 
process  involved  or  show  if  the  ulceration  has  occurred  in  healthy 
>kin  or  at  the  expense  of  an  infiltration  or  a  tumor. 

As  To  the  topographical  seat  of  the  ulcerations,  this  is  one  of  the 
signs  mosl  relied  upon  by  the  practitioner,  often  subconsciously, 
l.ut  not  without  reason.  The  fact  that  the  lesions  are  situated,  for 
example,  on  the  face,  the  genitals,  the  legs,  or  the  extremities,  in 
itself  supplies  a  valuable  indication,  often  limiting  the  field  of  the 
diagnostic  possibilities.  The  only  feature  of  ulcerations,  however, 
which  in  my  opinion  can  be  utilized  for  a  rational  classification,  is 
represented  by  their  course. 


ULCERATION  IN  GENERAL  279 

Pathogenesis. — The  mode  of  formation  of  ulcerations  is  variable. 
Exceptionally,  they  result  from  mortification  en  masse  of  a  more 
or  less  extensive  portion  of  the  tissues;  this  is  what  occurs  in 
the  gangrenous  dermatoses. 

Sometimes  a  dermic  ulceration  is  derived  from  deep  extension 
of  an  excoriation;  or  it  may  apparently  develop  in  healthy  skin; 
most  commonly  it  is  the  result  of  disintegration  or  partial  necrosis 
of  an  infiltration  (tuberculous  syphilitic,  leprous,  etc.),  or  of  a  tumor 
(epithelioma,  mycosis  fungoides,  etc.). 

In  all  these  cases,  the  loss  of  substance  results  from  the  necrosis 
or  necrobiosis  of  the  cellular  elements  and  of  the  tissue  framework, 
followed  by  their  molecular  disintegration. 

Without  entering  into  unnecessary  details,  it  is  sufficient  to 
emphasize  that  the  conditions  of  the  ulcerative  process,  as  far  as 
they  are  known,  may  be  of  two  orders.  One  of  these  conditions 
concerns  the  germ  or  virus  which  may  at  the  same  time  possess  a 
toxic,  necrotizing  and  digestive  or  lytic  property  and  be  able  for  a 
long  time  to  resist  the  defensive  measures  of  the  organism ;  as  is  the 
case  in  soft  chancre  and  very  probably  in  phagedenism. 

The  other  condition  refers  to  the  soil  and  consists  of  an  imperfect 
blood  supply,  due  to  preexisting  regional  vascular  lesions  (varicosi- 
ties, etc.),  or  to  the  effect  of  the  pathological  process  itself  (tubercu- 
losis, syphilis).  Sometimes  a  general  metabolic  disturbance  may 
be  held  responsible  [diabetes,  etc.]. 

Disturbances  of  innervation  undoubtedly  also  play  a  part,  not 
yet  fully  elucidated  but  proved  by  the  so-called  trophic  ulcers, 
such  as  malum  perforans,  ulcers  of  nerve-leprosy,  etc. 

Different  pathogenic  factors  are  often  combined. 

Etiology. — In  a  general  way  it  may  be  stated  that  all  agents 
injurious  to  the  tissues  may,  through  their  prolonged  activity,  give 
rise  to  and  maintain  ulcerations.  They  are  divided  into  mechanical, 
physical,  chemical  and  microbic  agents. 

Repeated  traumatisms,  by  tools,  shoes,  bandages,  or  badly  fitting 
apparatus,  produce  ulcerations.  Their  seat  and  form  are  often 
suggestive.  A  particular  instance  of  these  traumatic  ulcers  is 
furnished  by  the  setons  or  issues,  which  our  forefathers  believed 
it  advisable  to  establish  by  means  of  simple  or  epispastic  agents. 

As  regards  the  induced  [or  artificial]  ulcers  which  are  observed  on 
self-mutilators  and  malingerers  and  which  were  formerly  referred 
to  an  assumed  hysterical  pemphigus,  these  are  outside  of  any  possible 
general  description,  in  view  of  the  variety  of  means  employed  and 
their  results. 

Crevices,  rhagades,  fissures  or  cracks  are  usually  grouped  among 
ulcerations,  although  not  resulting  from  a  loss  of  substance;  they 
are  rather  linear  wounds  of  traumatic  origin  in  a  dermic  tissue 


280         ULCERATIONS   AM)    ULCERATIVE  DERMATOSES 

the  elasticity  of  which  may.  however,  have  beeB  impaired  by  a 
preceding  inflammatory  process. 

They  are  met  with  on  the  extremities,  mi  the  hands  and  feet,  as 
complications  of  a  hyperkeratosis,  or  at  the  circumference  of  the 
aatural  orifice-,  at  the  lips,,  especially  in  scrofulous  children,  at  the 
nipples  of  wet-nurses,  very  frequently  at  the  anus,  on  the  prepuce  of 
diabetics,  etc.  Under  the  influence  of  movements  of  extension,  the 
keratotic  or  macerated,  sometimes  even  eczematized  epidermis 
cracks  and  the  lesion  reaches  down  to  the  cutis.  The  borders  of 
the  crevices  are  perpendicular,  the  floor  is  bright  red,  sometimes 
bleeding;  pain  is  often  very  severe;  healing  may  take  place  without 
[visible]  scars. 


Fig.  95. — Tubular  epithelioma  in  the  form  of  ulcus  terebrans 


The  pain  of  cracks  or  crevices  is  relieved  by  local  anesthetics, 
cocain  and  analogous  remedies;  superficial  cauterizations  with 
[a  5  per  cent,  solution  of]  silver  nitrate  may  sometimes  prove  useful; 
it  often  suffices  to  apply  either  poultices  or  emollient  dressings,  or 
pastes  or  varnishes  containing  keratoplasty  or  keratolytic  agents, 
according  to  the  requirements  of  the  case. 

Among  the  ulcerations  resulting  from  physical  agents,  those 
due  to  burn-,  frost-bites,  .'-rays,  etc.  (Chapter  XXIII)  may  be 
mentioned. 

Various  toxic  agents  produce  pustulo-ulcerative  or  primarily 
ulcerative  lesions,  either  through  ingestion,  or  more  often  as  the 
result  of  externa]  application.  As  an  example  may  be  mentioned  the 
occupational  arsenical  ulcerations,  occurring  especially  on  the  hands 


ACUTE  ULCERATIONS  281 

and  sometimes  on  the  face  and  the  genitals  of  laborers  who  handle 
arsenic  or  its  compounds  [such  as  Paris  green]. 

The  principal  factors  of  ulcerations  are  microorganisms,  which 
are  concerned  either  exclusively  and  primarily,  or  in  cooperation 
with  other  causes.  This  matter  will  be  referred  to  again  in  connec- 
tion with  the  ulcerative  syndromes  in  particular. 

As  regards  the  ulcerations  of  tumors,  their  objective  features  and 
their  course  are  too  closely  connected  with  those  of  the  causative 
neoplasms  to  render  a  separate  description  advisable.  It  is  neces- 
sary to  state,  however,  that  in  some  exceptional  cases,  the  ulceration 
so  markedly  exceeds  the  neoplastic  process  that  the  latter  may 
remain  unrecognized.  This  rarely  happens  in  the  various  sarcomas, 
in  mycosis  fungoides  or  in  lobulated  epithelioma,  but  is  on  the  con- 
trary very  common  in  tubular  epithelioma  (Fig.  95),  which  was 
and  still  is  described  in  some  of  its  clinical  forms  under  the  name 
of  rodent  ulcer  or  ulcus  epitheliomatosum  terebrans. 

Ulcerative  Dermatoses. — Based  especially  upon  their  course,  I 
distinguish  between  the  following  groups: 

A.  Acute  Ulcerative  Dermatoses. — They  develop  rapidly  in  healthy 
skin,  never  assume  large  dimensions,  suppurate  frankly  and  freely 
and  are  usually  due  to  an  external  local  infection.  Soft  chancre  is 
typical  of  these  dermatoses. 

B.  Subacute  Ulcerative  Dermatoses. — They  are  derived  from  one 
of  the  great  subacute  infections,  more  particularly  syphilis,  tuber- 
culosis and  leprosy.  The  ulceration  takes  place  at  the  expense  of  a 
preliminary  newformation. 

C.  Phagedenic  Ulcers. — This  name  is  applied  to  ulcers  of  rapid 
spread  and  great  chronicity. 

D.  Chronic  Ulcerations,  or  True  Ulcers. — Their  pathogenesis  is  apt 
to  be  complicated. 

E.  Ulcerations  of  Mucous  Membranes. — The  excoriations  and  ulcer- 
ations of  mucous  membranes  are  discussed  in  a  separate  paragraph, 
because  it  seemed  to  me  convenient  for  the  reader  to  find  in  one 
place  important  data  on  the  diagnosis  of  lesions  of  the  mouth  and 
of  the  genital  organs;  these  data  will  practically  supplement  what 
has  already  been  stated  on  this  subject  in  Chapter  XL 

ACUTE  ULCERATIONS. 

Soft  Chancre. — Soft  chancre  (ulcus  molle)  or  chancroid,  which  will 
be  described  elsewhere  from  the  nosographical  viewpoint,  develops 
very  rapidly,  and  at  the  end  of  two  or  three  days  possesses  its 
typical  features. 

It  is  a  round  or  oval,  relatively  deep  ulceration,  the  size  of  a  pin- 
head,  a  lentil,  a  dime,  or  rarely  larger.    Its  borders  are  perpendicular, 


282        ULCERATIONS  AND  ULCERATIVE  DERMATOSES 

undermined  or  slightly  detached;  often  they  are  cracked  or  fissured. 
The  floor  is  of  a  creamy  yellow  or  yellowish  gray,  irregular,  "worm- 
eaten."  The  base  is  soft,  sometimes  doughy,  but  not  parchment- 
like or  cartilaginous.    The  circumference  is  red,  slightly  swollen. 

Soft  chancre  lias  an  abundant,  distinctly  purulent  discharge. 
It  is  rather  painful  on  touch  or  when  the  skin  of  the  region  is 
rubbed  in  moving.  It  is  rarely  single;  as  a  rule,  several  are  found, 
originating  from  the  same  contagion  or  from  successive  auto- 
inoculations.  This  was  humorously  expressed  by  Ivicord  when  he 
said  that  the  soft  chancre  is  a  family  man  and  lives  surrounded  by 
his  children.  In  some  cases,  in  persons  suffering  from  the  itch,  for 
instance,  over  a  hundred  soft  chancres  have  been  counted  on  the 
same   subject. 

The  corresponding  lymph  glands  are  usually  swollen  and  painful, 
one  among  them  often  greatly  preponderating.  This  glandular 
swelling  has  a  marked  tendency  to  suppurate  and  discharge,  under- 
going transformation  into  an  ulcer  representing  the  so-called  chan- 
croid bubo  of  French  writers. 

Soft  chancres  are  situated  in  the  genital  region  in  the  vast  majority 
of  cases.  They  may  occupy  any  point  of  this  region;  in  men,  the 
prepuce,  the  sulcus  coronarius,  the  frenum,  which  is  very  often 
perforated,  then  divided,  or  the  skin  of  the  penis  are  involved;  in 
women,  the  vestibule,  the  labia  minora,  the  fourchette,  the  pre- 
putium  clitoridis  and  frequently  the  anus.  In  the  last-named 
localization,  which  may  result  from  auto-inoculation,  the  chancre 
frequently  appears  double,  the  two  folds  of  the  ulcerated  surface 
resting  against  one  another,  while  its  swollen  lower  border  produces 
a  protuberance  resembling  a  condyloma. 

The  neighboring  regions — intergluteal  fold,  internal  aspect  of  the 
thighs,  pubis,  etc. — are  affected  in  a  considerable  number  of  cases. 

Extragenital  Soft  Chancres  are  rare.  They  may  be  observed  on 
the  fingers  or  on  the  hand  (Fig.  90),  where  they  are  often  misinter- 
preted; also  on  the  face,  although  the  existence  of  cephalic  soft 
chancre  was  formerly  denied. 

The  diagnosis  is  often  easy,  on  account  of  the  distinct  objective 
features,  the  topography,  the  usual  multiplicity,  the  rapid  course  of 
the  ulcerations  and  the  painful  glandular  swelling. 

In  doubtful  cases,  absolute  certainty  can  be  secured  by  means  of 
two  procedures:  (1)  Demonstration  of  the  specific  streptobacillus 
in  the  pus;  (2)  experimental  auto-inoculation,  which  is  valuable  in 
that  it  provides  a  conclusive  answer  within  forty-eight  hours. 
This  inoculation  should  be  made  in  the  deltoid  region;  as  soon  as 
it  has  been  recognized  as  positive,  the  focus  must  promptly  be 
destroyed  by  means  of  the  thermocautery.  In  all  doubtful  cases, 
such  as  will  be  described,  the  employment  of  these  two  diagnostic 


ACUTE   ULCERATIONS 


283 


procedures,  at  least  of  inoculation,  is  imperative,  as  the  treatment 
of  soft  chancre  demands  much  more  energetic  measures  than  are 
necessary  in  the  case  of  the  ulcerations  which  mav  simulate  it. 


Fig.   96. — Soft  chancre  of  the  back  of  the  hand. 


Other  Acute  Ulcerations. — Mixed  Chancre. — The  mixed  chancre 
of  Rollett  is  not  common,  but  has  been  observed  with  some  frequency 
during  the  war.  It  results  from  inoculation  at  the  same  point  with 
the  bacillus  of  soft  chancre  and  the  spirochete  of  syphilis.  When 
this  inoculation  has  been  simultaneous,  a  soft  chancre  develops  first ; 
at  the  end  of  two  to  four  weeks,  the  incubation  period  of  syphilis, 
the  base  of  this  chancre  becomes  distinctly  indurated,  its  surface  is 
modified  to  resemble  that  of  a  primary  lesion  and  a  generalized 
adenopathy  develops.  The  demonstration  of  the  spirochetes  in 
such  cases  is  very  difficult  and  the  diagnosis  usually  depends  on  the 
appearance  of  a  positive  Wassermann  reaction. 

When  the  inoculation  is  successive,  namely  when  an  indurated 
chancre  becomes  infected  with  virus  of  soft  chancre,  which  is  uncom- 
mon, the  transformation  occurs  in  the  opposite  direction.  One 
must  avoid  the  frequently  committed  error  of  applying  the  name 
mixed  chancre  to  a  soft  chancre  occurring  in  an  already  syphilitic 
subject,  who  therefore  presents  from  the  start  a  positive  Wassermann 
reaction.    The  treatment  must  of  course  be  both  local  and  general. 

Ulcerative  Syphilitic  Chancre. — The  primary  lesion  of  syphilis  is, 
as  a  rule,  simply  erosive  and  seems  to  be  an  insignificant  "  sore." 

In  exceptional  cases,  in  weakened  or  exhausted,  alcoholic  or 
diabetic  subjects,  in  localizations  predisposed  to  irritation  and  super- 
added infection,  indurated  chancre  becomes  ulcerative,  deeply 
invading  the  derma  and  burrowing  both  superficially  and  deeply. 
A  "chancre  terebrans"  may  perforate  the  prepuce  or  even  the  urethra 
in  men,  one  of  the  labia  minora  in  women,  etc.  The  ulcer  is  painful ; 
its  irritable,  proliferating,  granular  floor  resembles  that  of  a  soft 


284        ULCERATIONS  AND   ULCERATIVE  DERMATOSES 

chancre.  The  induration  of  the  base,  however,  is  often  verymarked; 
the  purulent  discharge  is  less  profuse  than  in  soft  chancre,  auto- 
inoculation  docs  not  occur  and  generalized  glandular  swelling 
supervenes. 

Ulcerative  Secondary  Syphilides.  'I  heir  course  may  be  very  rapid, 
or  subacute.    I  shall  have  more  to  say  concerning  them  later. 

Ulcerated  Herpes.  Although  herpes  is  primarily  vesicular  and 
ordinarily  gives  rise  only  to  very  superficial  erosions,  these  may 
become  deep  and  suppurate  under  certain  conditions  of  territory  or 
of  improper  treatment. 

The  differential  diagnosis  from  soft  chancre,  often  rather  difficult, 
pests  in  such  cases  on  the  polycj  clic  arrangement  of  the  lesions,  their 
simultaneous  appearance,  the  persistence  of  non-infected  herpetic 
elements  in  the  vicinity  and  especially  on  the  negative  outcome  of 
experimental    auto-inoculation   on   the  arm. 

Ecthyma.  This  consists  of  an  at  first  bullous  or  pustular,  secon- 
darily ulcerative  lesion.  It  affects  especially  the  lower  limbs,  some- 
times the  trunk  and  has  no  predilection  for  the  genital  region. 
The  ulcers  have  gently  sloping,  not  perpendicular  borders. 

In  all  the  cases  mentioned,  except  that  of  mixed  chancre,  micro- 
scopical examination  of  the  pus  in  smears  shows  the  absence  of  the 
streptobacillus;  inoculation  on  the  arm  produces  a  superficial 
impet  igo-pustule,  without  involvement  of  the  cutis  and  healing  of  its 
own  accord  in  at  most  three  or  four  days. 

SUBACUTE  ULCERATIONS. 

Syphilis  As  a  rule,  the  secondary  lesions  undergo  resolution,  the 
tertiary  lesions  alone  being  destructive  and  having  a  tendency  to 
ulcerate. 

Sometimes,  however,  beginning  with  the  first  eruption,  the  papulo- 
crusted  lesions  ulcerate  under  the  brownish  or  grayish  crust  which 
covers  them;  at  the  same  time,  more  or  less  extensive  and  destruc- 
tive ulcerations  appear  on  the  mucosa'.  These  eases  are  described 
;i-  syphilis  maligna  precox.  Weakened,  undernourished  or  alcoholic 
individuals  are  predisposed  to  it;  a  special  property  of  the  germ  has 
often  been  held  responsible  and  tropical  syphilis  is  of  bad  repute 
in  this  respect.  However,  this  special  course  has  also  been  noted  in 
robust  individuals  who  were  infected  by  a  syphilis  of  ordinary 
behavior.  So  much  is  certain  that  the  spirochetes  are  usually  rare 
in  the  malignant  syphilides,  although  inoculation  into  monkeys 
may  yield  a   positive  result. 

Ulcerative  secondary  syphilides  constitute  an  irregularly  scattered 
eruption  of  ulcerations  which  develop  and  enlarge  rapidly;  they 
have  a    round   or  more  often  oval  form,  perpendicular  purplish 


SUBACUTE   ULCERATIONS 


285 


borders,  a  cupola-shaped  floor,  filled  with  sanguinolent  pus,  and  a 
soft  base.  They  are  only  slightly  painful,  except  in  certain 
localities. 

Their  peripheral  extension  and  the  dessication  of  the  pus  which 
they  secrete,  sometimes  give  rise  to  ostreaceous  crusts,  thicker  in 
their  center;  this  picture  was  formerly  designated  under  the  name 
of  syphilitic  rwpia  (Fig.  94). 


Fig.  97. — Serpiginous  tuberculo-gummous  syphilides. 


Discrete  or  profuse,  sometimes  even  confluent  in  places,  the 
secondary  ulcerative  syphilides  sometimes  co-exist  with  deep  ulcer- 
ations of  the  mucous  membranes  and  do  not  readily  heal;  they 
leave  honeycombed  dyschromic,  sometimes  mutilating  cicatrices 
which  constitute  significant  stigmata.  They  are  usually  associated 
with  rapid  emaciation,  considerable  cachexia,  fever,  albuminuria 
and  pulmonary  or  digestive  complications  and  may  lead  to  death. 


286 


VLCERATIOXS   AM)    riJ'Eh'ATIYE   DERMATOSES 


Malignant  syphilis  had  been  observed  to  be  often  rather  resistant 
to  mercury  and  iodide  treatment,  and  in  addition  arsenic  medication, 
injections  of  hypertonic  sera,  a  strict  hygiene  and  careful  local 
dressings  were  recommended.  The  introduction  of  the  arseno- 
benzols  has  improved  the  prognosisof  this  form  of  the  disease;  their 
efficacy  is  remarkable  and  rapid;  it  is  recommended  to  combine 
their  action  with  that  of  injections  of  soluble  mercury  or  calomel. 

Ulcerative  tertiary  syphilides  are  derived  from  tubercles,  gumma, 
gummous  infiltration,  or  sclerosing  gumma.  All  of  these,  in  contra- 
distinction to  the  ulcerative  manifestations  of  the  secondary  period, 
are  generally  localized  or  regional.  Five  principal  types  are  dis- 
tinguished:   


it 


V 


, 


FlG.   98. — A  typical  syphilitic  ulceration  on  the  thorax  near  the  right  axilla. 

1.  Tvherculo-ulcerativb,  also  known  as  tuberculo-gummous  xii}>hi- 
lides  (Fig.  (.I7)  consist  of  rather  large  dermic  tubercles,  from  the 
size  of  a  pea  to  that  of  a  hazel-nut,  of  firm  consistence,  but  almost 
invariably  terminating  in  ulcerative  disintegration.  Usually  grouped 
in  clusters,  crescents,  etc.,  these  ulcerations  develop  excentrically 
and  become  arranged  in  serpiginous  patches  or  areas  of  a  highly 
characteristic  appearance.  These  areas  are  honeycombed  scars, 
checkered  with  whitish,  purplish  or  earthy  hues;  the  polycyclic 
border  presents,  sometimes  only  on  one  side,  rows  of  deep  ulcera- 
tions, round  or  in  their  turn  polycyclic  and  punched-out,  discharg- 
ing a  livid  pus,  or  covered  with  thick,  hard,  adherent,  sometimes 
ostreaceous  crusts  of  a  greenish-black  color.  The  double  polycyclic 
character  of  the  patch  and  of  its  constituent  ulcerations  possesses 
marked  diagnostic  value. 

'_!.  Syphilitic  ulcerations  which  may  be  called  atypical  have  a 
less  characteristic  appearance.  As  a  rule  it  cannot  be  determined 
whether  or  not  they  have  begun  under  the  form  of  tubercles;  at 


SUBACUTE   ULCERATIONS 


287 


any  rate,  none  are  found  at  the  circumference  of  the  resulting  lesion. 
This  is  usually  a  single  ulceration,  having  the  shape  of  an  oval,  a 
bean,  an  ear,  etc.,  with  regular  margins  describing  fairly  large 
curves,  often  with  a  moderately  hard,  raised  border  with  an  uneven 
rather  shallow  floor,  sometimes  cicatricial  in  the  center  (Fig.  98). 
Their  distinct  polycyclic  contours,  the  indurated  border,  the 
parchment-like  induration  of  their  base,  which,  however,  is  not 
always  easily  demonstrable,  the  examination  by  biopsy,  if  necessary, 
serve  to  differentiate  these  tertiary  ulcers  from  atypical  tuberculous 
ulcers  which  will  be  discussed  further  on ;  they  are  much  less  deeply 
evacuated  than  gummous  ulcers;  their  shape  is  more  regular  and 
their  progress  is  decidedly  more  rapid  than  that  of  an  epithelioma. 


Fig.  99. —  Syphilitic  gummous 
ulceration. 


Fig.  100.  —  Syphilitic  gummous  in- 
filtration, deeply  ulcerated  in  places. 
The  woman  from  whom  this  photograph 
is  derived  suffered  from  lesions  of  the 
same  kind  on  the  thighs,  the  thorax  and 
the  neck.  Cure  in  two  months  through 
calomel  injections. 


3.  Syphilitic  gummous  ulceration  is  a  deeper  lesion,  with  rounded 
or  kidney-shaped  contours,  and  loose,  soft  or  edematous  borders 
(Fig.  99).  It  results  from  the  disintegration  and  evacuation  of  a 
hypodermic  node. 


288        ULCERATIONS  AND   ULCERATIVE  DERMATOSES 

-i.  Ulcerated  gummous  infiltration  is  of  very  variable  extent, 
depth  and  configuration.  It  may  extend  to  the  tendons,  the  vessels, 
the  periosteum,  even  the  hones,  causing  very  serious  mutilations 
(Fig.  100). 

,").  Sclero-gummous  ulcerations  arc  those  which  originate  in  tertiary 
syphilitic,  sclerotic  or  scar-tissue.  They  are  observed  especially 
on  the  tongue,  though  sometimes  on  the  legs  or  in  hypertrophic 
syphilomas.  They  result  from  a  focal  or  a  superficial  necrosis,  dry 
and  caseous  at  first,  later  softening.  Their  abrupt  onset,  their 
irregular,  sometimes  angular  form,  the  woody  induration  of  their 
base,  the  slowness  of  their  repair,  are  sufficiently  characteristic. 

These  different  types  of  tertiary  ulcerations  are  connected  by 
numerous  intermediate  types.  There  is  always  a  more  or  less  dense 
and  circumscribed  specific  infiltration  of  variable  depth  which 
has  undergone  partial  necrosis  and  purulent  disintegration.  Their 
clinical  evolution  is  very  irregular,  sometimes  sluggish,  sometimes 
rapid.  Their  own  characteristics  commonly  suffice  for  a  positive 
diagnosis,  even  in  the  absence  of  a  history  or  other  evidence  of 
syphilis,  which,  however,  should  always  be  looked  for.  The  Wasser- 
niann  test  and  sometimes  examination  by  biposy  may  be  required. 
In  some  cases  the  mycoses  must  be  kept  in  mind.  These  tertiary 
syphilides  are  usually  very  amenable  to  the  influence  of  specific 
treatment . 

Tuberculosis.-  The  various  types  of  ulcerations  referable  to 
tuberculosis  differ  in  their  appearance,  their  seat,  their  pathogenesis 
and  also  to  a  high  degree  in  their  virulence,  but  they  are  associated 
by  connecting  links. 

Tuberculous  Ulcer. — Typical  tuberculous  ulcers  possess  peculiar 
features  which  as  a  rule  permit  them  to  be  quite  easily  recognized. 
Their  seat  of  predilection  is  on  the  lips  or  tongue,  or  at  any  point  of 
the  mouth  or  pharynx;  frequently  also  about  the  circumference  of 
the  anus;  rarely  elsewhere. 

These  ulcers  are  of  ovoid,  polycyclic  or  irregular  shape,  of  an 
extent  varying  from  a  few  millimeters  to  1  or  2  cm.,  with  wavy  or 
ragged  contours,  perpendicular  or  detached  borders,  of  a  livid  or 
purplish  color,  an  uneven  roughened  granular  floor,  dotted  with 
hemorrhagic  points,  often  partly  covered  by  grayish  detritus. 
Tuberculous  ulcers  are  almost  invariably  superficial,  rather  shallow. 

On  its  floor  or  at  its  periphery  may  be  seen  the  yellow  granules  of 
Trelat,  punctiform  or  of  pin-head  size,  in  greater  or  less  number; 
or  gray  miliary  ulcerations. 

The  discharge  is  sanious  and  rarely  profuse.  The  base  is  soft  or 
.-lightly  infiltrated.  The  regional  glands  are  often  enlarged.  Always 
tender  on  pressure,  tubercular  ulcers  may  become  distressingly 
painful  when  situated  at  points  exposed  to  traction  or  friction.    The 


SUBACUTE   ULCERATIONS 


289 


course  is  very  slow,  extending  over  weeks  and  months,  without 
showing  a  tendency  to  spontaneous  cicatrization. 

The  pathological  anatomy  of  this  ulcer  is  even  more  characteristic 
than  its  clinical  appearance  (Fig.  101). 

In  cases  of  rapidly  progressive  phthisis,  tuberculous  ulcers  of  the 
mouth  may  occasionally  be  seen  to  originate  and  extend  within  a 
few  days,  constituting  acute  buccal  phthisis. 


m : 


rn^j 


•■;.■'-=...■...      &   -v.  :■ 


f 


f  m 


Fig.  101. — -Histology  of  tuberculous  ulcer  of  the  tongue.  Section  from  the  margin 
of  the  ulcer.  6,  detached  margin  of  the  ulcer;  u,  floor  of  the  ulcer,  showing  a  light 
fibrinous  layer  which  covers  a  tissue  infiltrated  with  pus;  /,  /,  conglomerated  or 
isolated  tubercles;  they  are  usually  composed  of  one  or  several  central  giant  cells 
a  collection  of  clear  epithelioid  cells  and  an  external  zone  of  lymphocytes  and  plasmo- 
cytes.  None  of  these  tubercles  is  in  direct  contact  with  the  ulceration ;  g,  a  tubercle 
developed  in  a  papilla;  its  enlargement  or  its  confluence  with  other  neighboring 
tubercles  would  give  rise  to  a  yellow  granule  of  Trelat;  m,  striated  muscle  fibers  of 
the  tongue.      X  40. 

Sometimes,  the  ulcer  assumes  the  characteristics  of  the  fissured 
variety  being  elongated  in  the  diretion  of  a  fold  and  resembling  a 
rhagade  with  one  irregularly  ulcerated  portion.  This  is  observed 
at  the  commissures  of  the  lips,  their  median  furrow,  on  the  lateral 
borders  or  at  the  tip  of  the  tongue,  at  points  irritated  by  carious 
teeth;  or  again  in  the  radiating  folds  of  the  anus,  whence  the  ulcer- 
ation may  extend  to  the  anal  canal  on  the  one  hand  and  to  the 
integument  of  a  buttock  on  the  other. 

The  papillomatous  ulcerative  variety,  resulting  from  a  combination 
of  the  ulcer  with  a  process  analogous  to  that  of  papillomatous  or 
19 


290         ULCERATIONS  AXD   ULCERATIVE  DERMATOSES 

verrucous  tuberculosis,  is  likewise  not  uncommon.  The  bare  or 
keratotic  papillomatous  elevations  develop  on  the  congested  and 
cyanotic  floor  at  the  border  of  the  ulcer.  This  variety  is  seen 
especially  on  the  lips  and  at  the  anus. 

The  diagnosis  of  tuberculous  ulcer  is  usually  easy.  Traumatic 
ulcerations  heal  rapidly  when  properly  treated.  Soft  chancre  is 
exceptional  outside  of  the  genito-anal  region,  has  an  abundant  sup- 
puration, a  rapid  course  and  is  auto-inoculable.  Syphilitic  ulcers 
have  a  more  regular  form  and  an  indurated  base;  in  difficult  or 
doubtful  cases,  recourse  may  be  had  to  serodiagnosis  and  the  demon- 
stration of  the  bacillu.-.  Asuspicionof  ulcerated  epithelioma  makes 
the  microscopical  examination  by  biopsy  imperative. 

Whenever  the  clinical  features  of  the  ulcer — although  fairly  char- 
acteristic — and  the  conditions  under  which  it  appears  are  not  suffi- 
cient to  remove  all  doubts,  the  diagnosis  must  always  be  confirmed 
by  laboratory  tots.  The  tissue-fragments  obtained  by  scraping 
the  floor,  or  better  still  from  under  the  margins  of  the  ulcer,  contain 
bacilli;  but  it  is  necessary  to  scrape  the  tissues  rather  forcibly  with 
a  curette,  bringing  a  little  blood.  Biopsy  also  must  go  rather  deep. 
Inoculation  into  guinea-pigs  may  sometimes  be  necessary. 

Lupus  Ulcerations. — The  ulceration  of  a  lesion  of  lupus,  whether 
delayed  or  appearing  at  once  on  a  lupus  exedens,  always  presents 
certain  definite  features  which  have  been  pointed  out  by  Du  Castel. 

The  borders  are  slanting,  the  adjoining  tissue  is  purplish  or 
brownish-yellow,  tense,  infiltrated,  more  or  less  transparent,  soft, 
swollen,  or  covered  with  flabby  proliferations. 

The  shape  of  the  ulcer  is  round  or  oval,  somewhat  regular.  Its 
floor  is  slightly  depressed,  of  a  lardaceous  gray,  light  red  or  brownish 
color,  sometimes  proliferating;  it  bleeds  easily,  is  of  spongy  con- 
sistence and  is  readily  lacerated. 

The  base  is  the  seat  of  a  soft,  non-plastic  infiltration,  more  often 
movable  than  adherent  to  the  subjacent  tissues. 

The  secretion  is  turbid,  sanious,  drying  in  thin  adherent  grayish- 
yellow  crusts,  which  are  deeply  imbedded  and  rarely  ostreaceous. 

Extension  may  be  either  superficial  (lupus  serpiginosus) ,  or  deep 
I  lupus  terebrans),  or  finally  in  all  directions  (lupus  vorax). 

Ulcerated  Tuberculides. — Leaving  out  of  consideration  the  minute 
punctiform  ulcerations  of  the  papulo-necrotic  tuberculides,  mention 
musl  lie  made  of  the  sometimes  extensive  ulcers  of  erythema  indur- 
(ituin.  They  constitute  rather  deep  depressions,  with  variable 
borders,  a  grayish  or  mammillated  and  reddened  floor  and  an  exten- 
sively indurated  base,  all  of  which  taken  together  with  the  purplish 
hue  of  the  circumference  and  the  seat  of  the  lesion  on  the  legs,  invests 
them  with  a  peculiar  appearance  (Fig.  102). 

Occasionally  they  coincide  with  scrofulo-tuberculous  gummas. 


SUBACUTE   ULCERATIONS 


291 


Atypical  Tuberculous  Ulcers. — Under  this  name  I  describe  a  clinical 
form  which  is  not  very  uncommon  and  the  diagnosis  of  which  is 
always  most  baffling.  These  ulcers  are  usually  met  with  in  youthful 
individuals  of  the  female  sex  who  at  the  same  time  present  either 
pulmonary  lesions  with  a  sluggish  course,  or  cutaneous  tuberculides. 


Fig.  102. — Large  ulcerated  tuberculide  of  the  thigh,  in  a  young  woman  suffering 
besides  from  scrofulo-tuberculous  gummas  and  papulo-necrotic  tuberculides.  Cure  in 
six  weeks,  under  the  influence  of  rest,  good  hygiene,  injections  of  tuberculin  and  aseptic 
dressings. 


The  ulcers  are  rounded,  oval,  or  polycyclic,  from  the  dimensions 
of  a  silver  quarter  to  that  of  the  palm  of  the  hand,  single  or  multiple, 
situated  on  any  part  of  the  integument.  I  have  observed  them  on 
the  shoulder,  the  neck,  the  chest,  the  groins,  thighs,  instep,  etc. 
The  irregularly  outlined  borders  are  often  partly  sloping,  partly 
perpendicular  or  detached,  of  a  dusky  red  or  purplish  color;  the 
floor  is  grayish  or  bright  red  and  proliferating;  there  are  no  yellow 
points,  no  lupus  nodules;  the  base  is  slightly  infiltrated  and  not 
indurated;  they  are  absolutely  painless.  The  course  is  extremely 
sluggish  (Fig.  103). 

The  diagnosis  lies  between  ulcerative  tertiary  syphilide,  con- 
genital syphilitic  ulcer,  abnormal  tuberculous  ulcer  and  ulcerated 
tuberculide.     Laboratory  investigations  are   required   and    yield 


292         ULCERATIONS   AND   ULCERATIVE   DERMATOSES 

variable  results.  In  the  form  of  atypical  tuberculous  ulcer 
described  by  Man-el  LeVy-Bruhl  (These  de  Paris,  L914),  the  his- 
tological lesions  are  clearly  tubercular  associated  with  vascular 
changes;  the  local  tuberculin  reaction  and  guinea-pig  inoculation 
are  positive. 

In  clinically  analogous  eases  I  was  unable  to  produce  tubercular 
infection  in  guinea-pigs.  The  degree  of  virulence  of  these  atypical 
ulcers  is  accordingly  not  uniform.  They  are  apparently  due  to 
bacillary  emboli  rather  than  to  external  inoculations.  The  treat- 
ment of  election  is  surgical  extirpation;  aside  from  this,  a  very 
favorable  action  is  exerted  by  tuberculin  therapy  and  radiotherapy, 
combined  with  scarifications. 


.luloso 


ilcer  < >f    the    presternal    region,   co-incident  with 
: i trc-<  1  seventeen  years.     Case  of  Levy-Bruhl. 


Leprosy.  The  ulcers 
course  and  pathogenesi: 
differentiated  from  tub 
are  observed  especially 


if  leprosy  have  a  variable  appearance, 
First,  the   ulcerated  lepromas  must  be 

•les  or  subcutaneous  nodosities.  They 
countries  where   leprosy   is  endemic,  in 


severe  cases,  affecting  neglected  and  badly  cared-for  individuals 
who  drag  along  a  miserable  existence.  The  loss  of  substance  results 
from  partial  disintegration  of  a  bacillary  infiltration,  the  remains 
of  which  are  found  at  the  circumference  and  at  the  base  and  becomes 
aggravated  in  consequence  of  vascular  lesions  and  secondary  infec- 
tions.   These  lepromatous  ulcers  lead  to  serious  mutilations. 


SUBACUTE   ULCERATIONS  293 

Leprous  individuals  are,  on  the  other  hand,  exposed  to  trophic 
ulcers,  especially  in  the  nervous  or  mixed  types.  Consecutive  to, 
or  associated  with  pemphigus  leprosa,  these  are  very  superficial  at 
first  but  obstinate  and  soon  become  covered  with  a  rupioid  crust; 
later  on,  they  spread  but  retain  a  regular  configuration,  perpen- 
dicular walls  and  a  membranous  floor.  They  are  hyperesthetic  or 
anesthetic.  When  there  are  no  other  symptoms  besides  anesthesia, 
the  ulcers  are  characteristic  of  Lazarine  leprosy.  Bacilli  may  be 
found  in  these  ulcers  at  the  period  of  onset. 

Glanders. — The  ulcerations  which  follow  upon  the  abscesses  or 
nodosities  of  chronic  glanders,  formerly  called  farcy,  may  present 
a  fairly  characteristic  appearance,  or  on  the  contrary  very  closely 
simulate  tuberculous,  syphilitic  or  epitheliomatous  ulcers 

The  features  peculiar  to  them  are:  their  irregular  shape,  their 
livid  purplish  margins,  undermined  and  ragged  as  if  torn  by  the  teeth 
of  mice,  their  very  irregular  sinuous  floor,  the  softness  of  their  base, 
their  painlessness;  furthermore,  the  presence  of  fluctuating  nodosities 
or  small  abscesses  at  their  periphery. 

Mutilating  glanders  is  apt  to  be  situated  in  the  center  of  the  face, 
and  causes  considerable  disfigurement  and  mutilation.  The  course 
is  slow,  irregular  and  progressive.    The  usual  outcome  is  death. 

The  diagnosis  can  be  surmised  under  certain  conditions,  but  is 
positively  established  only  by  means  of  cultures  and  animal  inocu- 
lation. 

Dermatomycosis. — The  ulcerations  of  sporotrichosis,  blasto- 
mycosis, actinomycosis,  and  mycetoma  (Chapter  XXYIII)  follow 
gummous  nodosities,  or  sometimes  after  tuberculo-ulcerative  and 
ecthymato-pustular  dermic  lesions.  The  pus  contains  the  specific 
parasites,  demonstrable  on  direct  examination  or  by  means  of 
cultures. 

Phagedena. — Phagedenic  ulcers  are  characterized  by  a  very 
marked  tendency  to  invade  the  neighboring  tissues,  superficially 
or  deeply,  continuously  or  with  interruptions;  or  rather  at  intervals; 
they  are  accordingly  acute  in  their  course  and  chronic,  in  their 
duration. 

These  ulcers  take  their  start  in  various  lesions,  as  if  due  to  the 
effect  of  a  complication  or  a  malignant  change.  The  initial  lesion  is 
very  often  a  soft  chancre,  rarely  a  hard  chancre  and  not  infrequently 
a  tertiary  ulcerative  syphilide  or  a  congenital  syphilide;  sometimes 
it  is  a  lesion  of  ecthyma  or  a  patch  of  spontaneous  gangrene. 

It  goes  without  saying  that  not  all  extensive  ulcerations  must  be 
grouped  under  the  heading  of  phagedena — such  as  malignant 
secondary  syphilides,  tertiary  syphilitic  ulcers,  tuberculous  ulcers, 
cancerous  ulcers,  the  ulcers  of  tropical  diseases,  etc., — but  only 
those  which  assume  a  both  prolonged  and  rapidly  destructive  course, 


2!)4         ULCERATIONS  AND   ULCERATIVE  DERMATOSES 

not  an  ordinary  attribute  of  their  kind.  The  phagedenic  nicer  of 
hot  countries  will  he  discussed  further  on. 

Provided  the  necessary  exclusions  are  carefully  made,  it  will  be 
seen  that  no  matter  what  may  he  the  original  lesion,  phagedenic 
nicer  presents  a  rather  uniform  picture,  to  he  presently  described. 
Tin-  observation  has  led  the  majority  of  writers  to  believe  that 
phagedena  is  due  to  a  superadded  infection,  a  special  bacterial 
agent,  or  a  microbic  association  of  particular  virulence.  Bacteriology 
having  not  as  yet  confirmed  this  theory,  the  conditions  of  the  soil 
have  been  held  responsible.  It  is  true  that  phagedena  sometimes 
attacks  weakened  or  alcoholic  subjects,  but  often  also  robust 
individuals;  one  is  obliged  to  suspect  in  the  latter  a  peculiar  sus- 
ceptibility or  a  deficient  resistance  against  certain  infections  agents. 
Although  the  majority  of  cases  of  phagedena  occur  in  syphi- 
litica, they  do  not  all  have  syphilis.  Age  and  sex  are  apparently 
irrelevant. 

A  phagedenic  nicer  is  of  very  variable  extent,  according  to  the 
activity  and  duration  of  the  process.  In  a  few  weeks  or  months, 
starting  from  the  genital  organs,  it  may  have  destroyed  the  larger 
part  of  the  penis  or  the  vulva,  reached  the  thighs,  the  perineum  and 
the  buttocks;  have  invaded  a  considerable  portion  of  the  abdomen 
and  the  back;  in  the  face  it  may  have  destroyed  the  nose,  the  lips, 
a  cheek,  etc.  It  involves  practically  always  the  entire  thickness  of 
the  integument;  when  it  burrows  deeply,  exposing  the  muscles, 
tendons,  large  bloodvessels,  etc.,  it  is  described  as  terebrans:  it  is 
called  serpiginous  when  it  becomes  partly  cicatrized  while  elsewhere 
progressing. 

The  configuration  of  the  nicer  is  sometimes  irregular,  often  poly- 
cyclic.  Brocq  pointed  out  an  objective  appearance  which  is  most 
characteristic  and  which  lie  names  geometrical  phagedena,  because 
its  distinctly  marked  borders  form  perfect  circles  or  ovals  or  parts  of 
circles  and  ovals  as  if  traced  with  a  compass. 

The  borders,  surrounded  by  a  red  and  infiltrated  zone,  from  4 
to  20  mm.  wide,  are  perpendicular,  sometimes  undermined,  with 
pockets  of  pns;  in  other  eases  sharply  sloping.  The  floor,  after  it 
has  heen  cleansed  of  the  thick  and  yellow,  rather  than  sanions  pus 
which  covers  it,  appears  raw,  red  and  granular,  or  sprinkled  with 
shreds  of  sphacelated  tissues.  The  center  is  sometimes  epidermi-zed 
and  crusted. 

The  invasion  is  rapid,  fulminating  in  some  eases;  as  a  rule,  its 
progress  is  much  more  pronounced  at  some  points  than  at  others. 
The  corresponding  glands  are  usually  swollen  and  painful,  but  they 
rarely  suppurate.  Although  sometimes  painless,  the  nicer  is  more 
apt  to  he  tender  or  even  extremely  painful  on  contact. 

Histological   examination  shows  a  severe  phlegmonous  process 


SUBACUTE   ULCERATIONS  295 

with  a  tendency  to  rapid  necrosis,  but  a  not  very  extensive  range 
(Dominici,  Rubens-Duval  and  CI.  Simon). 

Bacteriology  shows  nothing  but  staphylococci,  often  streptococci, 
but  no  specific  agent.  Fuso-spirillary  organisms  and  the  Bacillus 
ramosus  of  Villon  are  absent.  The  search  for  anaerobes  will  have 
to  be  kept  up. 

Personally,  in  all  cases  which  I  have  recently  observed,  the  bacil- 
lus of  Ducrey  has  been  looked  for  without  success;  but  I  have 
always  found  the  pus  to  be  auto-inoculable  on  the  patient's  arm, 
producing  a  typical  chancroid,  only  remarkable  by  a  delayed  develop- 
ment which  may  last  from  three  to  five  days.  [It  is  noteworthy 
that  in  these  inoculated  chancroids  phagedenism  does  not  develop]. 
This  would  lead  me  to  assume  that  a  large  proportion  of  the  most 
characteristic  phagedenas,  although  evidently  not  all  of  them,  are  of 
chancroidal  character.  Caution  is  needed,  for  it  is  not  in  the  nature 
of  the  chancre  bacillus  to  remain  indefinitely  virulent  in  the  same 
subject;  furthermore,  phagedena  rarely  gives  rise  to  spontaneous 
auto-inoculations  or  chancrous  bubos. 

Although  the  appearance  of  phagedena,  as  previously  stated,  is 
nearly  always  uniform  whatever  its  origin,  it  is  desirable  to  point 
out  some  peculiarities  of  the  various  formerly  admitted  types. 

Chancroidal  phagedena  is  by  far  the  most  common.  It  originates 
in  a  soft  chancre  or  in  an  open  chancrous  bubo  and  is  therefore 
observed  especially  in  the  genital  and  inguinal  regions.  It  does  not 
possess  the  special  features  of  chancrous  ulcer,  cracked  or  fissured 
borders,  a  yellowish  worm-eaten  floor,  etc.  I  have  seen  it  growing 
by  true  subdermal  abscesses,  opening  at  the  surface  or  under  the 
margins  of  the  ulcer,  where  they  form  burrows  and  extensive  puru- 
lent tracts.  Chancrous  phagedena,  derived  from  a  syphilitic  chancre, 
is  rare,  unless  one  comprises  incorrectly  under  this  denomination 
the  giant  chancres  and  perforating  chancres  (terebrans)  which  may 
perforate  the  urethra  in  men,  or  the  labia  of  the  vulva,  the  lips,  etc. 

Tertiary  phagedena,  referable  to  a  tuberculo-gummous  syphilide 
or  a  gumma,  has  its  seat  of  predilection  in  the  middle  of  the  face  or 
on  the  genital  organs.  It  may  cause  enormous  mutilations,  with 
fulminating  rapidity,  destroying,  for  example,  the  cheek,  the  nose, 
the  upper  jaw,  the  turbinates,  the  roof  of  the  palate,  hollowing  out 
an  enormous  cavity  in  the  middle  of  the  face;  the  destruction  is  no 
less  considerable  in  the  pharynx  or  about  the  genitals.  On  the  trunk 
and  the  extremities,  it  has  been  noted  that  phagedena  often  exposes, 
without  attacking  them,  the  large  bloodvessels  and  the  nerves. 

The  course  of  the  phagedenic  process  varies  in  different  cases, 
and  even  in  the  course  of  development  of  the  same  case.  Par- 
tial cicatrization  by  itself  alone  is  not  a  reassuring  symptom,  for 
extension  may  continue  elsewhere  or  the  cicatrix  become  eroded  in 


296        ULCERATIONS  AND   ULCERATIVE  DERMATOSES 

its  turn.  The  total  duration  of  the  course  of  a  phagedena  usually 
extends  over  several  years,  up  to  four  or  five  years,  ten  years  or 
longer.  The  patients  do  not  become  cachectic,  but  the  exquisite 
pain  with  each  dressing  causes  them  to  become  weakened  and 
demoralized.  Death  from  hemorrhage  or  septicemia  rarely  super- 
venes. 

Treatment.-  In  the  presence  of  genuine  phagedena,  in  a  syphilitic 
patient,  general  specific  treatment  must  not  be  considered  as  suffi- 
cient. Mercurial  medication,  even  when  energetic  and  supported 
by  adjuvants  and  excellent  hygiene,  usually  fails;  intravenous 
injections  of  arsenobenzol  are  positively  indicated  at  the  present 
day,  hut  may  prove  insufficient. 

In  view  of  the  rapidity  with  which  phagedena  exerts  its  destruc- 
tive effects,  local  medication  is  imperative  and  must  be  very  ener- 
getic from  the  start.  The  method  of  choice  is  the  destruction  of  the 
infectious  focus  as  a  whole  with  superheated  air,  under  general 
anesthesia.  Extensive  removal  with  the  bistoury  is  likewise  advo- 
cated, in  the  rare  cases  where  it  is  practicable.  When  these  measures 
are  inapplicable,  recourse  must  be  had  to  cauterization  with  the 
thermocautery,  zinc  chloride,  or  tincture  of  iodin,  which  are  of 
value  only  provided  all  the  anfractuosities  of  the  ulcer  are  reached. 
At  the  same  time,  or  in  the  milder  cases,  repeated  irrigation 
or  washing  with  peroxide  solution  or  hot  potassium  perman- 
ganate solutions.  All  kinds  of  antiseptic  dressings  and  all  varieties 
of  powders  have  been  tried.  Brocq  has  obtained  excellent  results 
with  a  10  per  cent,  collargol  salve.  [The  Carrel-Oakin  solution 
ought  to  give  good  results].  In  these  cases  where  the  presence  of 
chancroidal  virus  is  probable  or  certain,  no  time  should  be  lost  with 
iodoform  or  silver  nitrate,  etc.,  but  the  heroic  measures  named  above 
should  be  employed,  notably  hot  air.  Auto-inoculation  on  the  arm, 
which  experience  has  shown  to  be  devoid  of  special  danger,  will 
serve  to  show  if  at  a  given  point  which  may  continue  to  appear 
suspicious  after  the  general  cauterization,  virulent  germs  are  still 
present  and  require  renewed  intervention.  General  tonic  treatment 
and  excellent  hygiene,  although  insufficient  by  themselves,  may 
favor  the  cicatrization  after  the  ulcer  has  been  transformed  into  a 
simple  wound. 

ULCERS. 

Ulcus  Cruris.  I  leer  of  the  leg,  also  known  as  .simple  ulcer  or 
varicose  ulcer,  is  a  syndrome  into  the  etiology  of  which  a  large 
number  of  conditions  of  various  kinds  enter. 

The  seat  of  predilection  of  simple  ulcer  is  on  the  lower  half  of  the 
legs,  somewhat  more  frequently  on  the  left  leg,  at  the  inner  aspect 
and  above  the  malleolus.     It  is  usually  single,  sometimes  multiple, 


ULCERS 


297 


and  in  this  case  with  a  tendency  to  coalescence  of  the  various  ulcers ; 
its  shape  is  oval,  polylobar  or  polycyclic  and  its  extent  may  reach 
15  and  20  cm.  in  diameter.  Its  floor  is  bright  red  or  purplish,  pro- 
liferating, oozing,  or,  in  the  absence  of  suitable  care,  covered  with 
grayish  detritus  and  sanious  offensive  pus.  The  borders  are  ad- 
herent, gently  sloping  or  perpendicular,  sometimes  detached,  thick- 
ened and  callous  (Fig.  104).  The  discharge  is  very  variable,  scanty 
and  seropurulent  when  the  patient  remains  in  bed. 


Fig.  104. — Varicose  ulcer  of  the  leg,  with  callous  margins. 


Sensibility  is  usually  diminished  and  delayed  on  the  ulcer  and  in 
its  circumference,  especially  thermic  sensibility,  although  painful 
and  tactile  perception  are  also  lessened. 

The  periphery  of  the  ulcer  may  be  erythematous  in  a  more  or  less 
extensive  area,  but  otherwise  normal;  this  is  rare.  As  a  rule,  the 
neighboring  and  adjacent  tissues  are  the  seat  of  various  changes, 
some  depending  on  causes  which  have  prepared  the  soil  of  the  ulcer, 
others  on  secondary  infections,  unclean  dressings,  etc. 

The  complications  consist  of:  Varicosities,  which  will  be  referred 
to  again  presently;  varicose  eczema,  often  circumscribed,   which 


298        ULCERATIONS  AND   ULCERATIVE  DERMATOSES 

may  be  dry,  scaly,  cracked,  crusted,  oozing,  rubrum,  impetiginous, 
etc.,  pigmentation  of  clay  color,  resulting  from  repeated  intradermic 
hemorrhages;  lymphangitis,  more  or  less  acute,  or  mild  and  recur- 
rent; edema,  sometimes  soft  and  plastic,  or  more  frequently  non- 
depressible,  elephantiasti< — a  hypertrophic  callous  state,  or  on  the 
contrary  a  sclerotic  atrophy.  These  last  named  lesions  are  entitled 
to  a  moment's  attention. 

Leu  ulcer  in  the  callous  state  has  thickened,  infiltrated,  prominent 
borders,  of  cartilaginous  or  woody  hardness;  they  slope  rapidly  in 
both  directions  and  particularly  steeply  on  the  side  of  the  loss  of 
substance,  which  is  often  pale  and  covered  with  grayish  detritus. 
The  induration  extends  below  the  ulcer,  and  more  or  less  far  on  the 
leg  and  foot;  it  involves  not  only  the  skin,  but  all  the  subjacent 
tissues,  down  to  the  bones. 

These  callous  ulcers  are  sluggish,  obstinate,  extensive  and  not 
readily  curable. 

The  fibrous  induration  may  terminate  in  hypertrophy,  in  a  second- 
ary elephantiastic  state,  determined  by  inflammatory  lesions  of  the 
lymphatics,  bloodvessels  and  nerves.  The  bulk  of  the  limb  may 
become  enormous  and  present  deformities — which  will  be  discussed 
under  the  heading  of  elephantiasis — with  a  supramalleolar  cushion 
and  swelling  of  the  dorsum  of  the  foot  and  the  toes.  The  surface 
is  smooth  or  hyperkeratotic,  or  more  frequently  papillomatous  and 
verrucous. 

In  other  cases  the  skin  in  the  vicinity  of  the  ulcer  is  in  a  state  of 
diffuse  or  reticulated  sclerotic  atrophy;  under  these  conditions  it  is 
thickened,  smooth,  tense,  cannot  be  folded  and  presents  a  mottled, 
white,  brown  or  purplish  color.  It  is  common  for  this  dermato- 
sclerosis  to  precede  the  formation  of  the  ulcer. 

The  inguinal  glands  are  often  enlarged,  the  tendon  reflexes  of  the 
limb  may  be  absent;  there  is  sometimes  a  slight  muscular  atrophy. 

The  nails  of  the  foot  are  usually  discolored,  opaque,  stratified,  or 
even  in  a  condition  of  pronounced  onychogryphosis.  It  is  not  rare 
t'oi-  the  hairy  system  to  be  hypertrophied  and  for  hyperidrosis  to 
exist.  These  accessory  lesions  are  often  present  on  both  sides, 
although  the  leg  ulcer  is  unilateral  in  the  majority  of  the  eases. 

Varicosities,  which  almost  invariably  accompany  ulcer  of  the  leg 
and  exist  on  both  lower  limbs,  rarely  form  large  subcutaneous 
strands.  The  latter  do  not  predispose  to  ulcer  so  much  as  the  deep 
varicosities,  which  are  not  very  visible  and  are  not  perceived  unless 
the  patient  stands  up,  or  by  very  careful  palpation.  They  give  rise, 
prior  to  the  formation  of  the  ulcer,  to  pigmentations  in  patches, 
reticulated,  or  in  the  form  of  an  areola  around  a  cicatrix;  to  telan- 
giectasis; predispose  to  edema  and  eczema,  and  cause  cramps, 
itching  and  a  sensation  of  heaviness  of  the  limb. 


ULCERS  299 

The  ulcer  begins  in  a  variable  manner;  as  the  result  of  a  wound, 
an  ecchymosis,  a  small  traumatic  scar,  a  venous  rupture,  a  small 
focus  of  phlebitis,  an  eczematous  lesion,  an  impetigo  or  ecthyma 
pustule — all  these  lesions,  instead  of  rapidly  healing  as  they  would 
on  a  well-nourished  soil — persisting,  becoming  infected,  deepening 
and  enlarging  under  the  crust  which  covers  them. 

It  is  exceptional  for  leg  ulcer  to  begin  as  a  plaque  of  spontaneous 
gangrene,  although  I  have  several  times  observed  this  occurrence. 

Etiology. — Ulcer  of  the  leg  is  observed  especially  between  the 
ages  of  thirty-five  and  sixty  years,  slightly  oftener  in  the  male  sex, 
in  fatiguing  occupations  which  require  the  erect  position;  in  women 
who  have  had  numerous  pregnancies  and  in  the  poorer  classes. 
The  patients  are,  as  a  rule,  atheromatous;  sometimes  polysclerotic, 
especially  with  renal  sclerosis. 

To  the  role  played  by  deep  varicosities  as  an  etiological  factor, 
established  by  Verneuil,  has  been  added  that  of  neuritis,  deemed  by 
Quenu  to  be  itself  of  varicose  origin;  furthermore,  that  of  arteritis. 

It  is  readily  understood  that  these  general  and  local  conditions 
impede  the  healing  of  the  small  above-enumerated  lesions.  This  is 
not  all,  however.  On  this  undernourished  and  poorly  resistant  soil, 
microbic  infections  are  grafted  and  come  to  play  the  decisive  part 
in  the  ulcerative  process,  in  the  recurrent  lymphangitides,  and  in 
their  sequel,  dermatosclerosis. 

Among  the  innumerable  microorganisms  of  all  kinds  which 
flourish  on  these  ulcers,  the  principal  pathogenic  agent  seems  to  be 
most  commonly  the  streptococcus.  Leg  ulcer  has  been  described  as 
"a  chronic  streptococcic  chancre"  (Sabouraud). 

This  local  streptococcia  is  indefinitely  prolonged,  sometimes 
latent  during  long  periods  of  time;  not  infrequently,  the  presence 
of  the  Bacillus  pyocyaneus  is  likewise  demonstrable. 

Still  other  parasites  when  favored  by  special  local  conditions  may 
undoubtedly  give  rise  to  a  symptom-complex  identical  with  that  of 
simple  ulcer. 

It  has  long  been  noted  that  leg  ulcers  of  typical  appearance,  in 
admittedly  syphilitic  individuals  as  well  as  in  cases  of  undetected 
syphilis,  will  heal  under  mercurial  medication.  More  recently, 
objectively  similar  cases  have  been  recognized  as  tuberculous, 
through  experimental  inoculation.  It  is  not  known,  however,  to 
what  extent  these  specific  infections  are  involved. 

Diagnosis. — The  essential  point  consists,  not  in  the  recognition  of 
the  syndrome  of  leg  ulcer,  but  in  determining  what  part  is  referable 
to  general  and  local  predisposition  as  well  as  to  the  ordinary  or 
specific  infections. 

Simple  ecthyma  is  distinguished  by  the  multiplicity  of  its  lesions, 
their  acute  inflammatory  character  and  their  course. 


300        ULCERATIONS  AND   ULCERATIVE  DERMATOSES 

Ulcerative  syphUides  and  syphilitic  gummas  are  usually  multiple 
and  bilateral,  preferably  situated  on  the  external  aspect  of  the  legs. 
The  former  are  often  grouped  in  ares  of  circles.  Gummas  begin  as 
a  nodosity  and,  after  ulceration  has  occurred,  are  characterized  by 
their  rounded  shape  and  undermined  borders. 

So-called  tuberculous  ulcer*  follow  upon  bony  lesions  or  scrofulo- 
tuberculous  gummas,  or  upon  fungoid  or  lupoid  tuberculosis,  which 
are  recognized  by  their  special  features. 

Ulcerative  erythema  induratum  of  Hutchinson's  type  is  met  with 
only  in  youthful  persons. 

As  stated  above,  these  affections  may  lose  their  specific  marks  in 
a  varicose  and  sclerotic  territory. 

Treatment. — This  is  medical  or  surgical.  Innumerable  methods 
and  remedies  have  been  advocated.  In  the  first  place,  it  is  most 
essentia]  to  insist  upon  rest  in  the  recumbent  position,  with  the  foot 
slightly  elevated.  The  inflammation  should  be  soothed  and  the 
ulcer  cleansed  by  prolonged  local  baths,  application  of  powders, 
aseptic  or  weakly  antiseptic  cytoplastic  moist  dressings.  Strong 
antiseptics  being  rather  injurious.  [Liq.  aluminii  acetatis,  one  part 
to  ten  of  water  is  one  of  the  best  of  these  moist  dressings.] 

After  improvement  has  begun  and  the  inflammation  subsides,  the 
formation  of  healthy  granulations  must  be  stimulated  by  means  of 
dry  dressings  with  inert  or  weakly  stimulating  powders,  aristol, 
iodoform,  iron  subearbonate,  collargol,  etc.,  the  old  styrax  oint- 
ment, which  has  lost  nothing  of  its  value  as  a  stimulant,  as  well  as 
balsam  of  rem. 

Modern  procedures  may  also  be  resorted  to,  such  as  light  baths, 
radiotherapy,  high-frequency  currents,  hot  air;  they  sometimes 
exert    a   highly  favorable  action. 

Imbricated  strips  of  adhesive  plaster,  or  better  still,  dressings  with 
cotton  or  zinc  glycerin-gelatin,  which  is  valuable  in  these  cases,  or 
with  elastic  bands,  may  permit  the  patient's  attending  to  some  of 
his  work.  It  is  advisable  not  to  change  the  dressings  too  frequently 
in  leg  ulcers  that  are  healing. 

The  remarkably  rapid  healing  of  certain  leg  ulcers  of  ordinary 
appearance  under  the  influence  of  mercurials,  notably  calomel 
injections,  led  to  the  adoption  of  the  general  rule  always  to  give 
mercury  a  trial.  At  the  present  day,  serodiagnosis  should  be  called 
upon  in  all  such  cases  and  its  indications  be  followed. 

Surgical  procedures,  such  as  circumvallation,  radiating  incisions, 
etc.,  are  merely  mentioned  by  name  in  this  connection,  but  it  should 
be  kept  in  mind  that  carefully  and  judiciously  applied  grafts  may 
greatly  shorten  the  time  of  cicatrization  and  furnish  a  better  scar. 
In  a  few  incurable  cases  of  callous  ulcer  surrounding  the  entire  leg, 
amputation  has  proved  unavoidable. 


ULCERS  301 

After  a  leg  ulcer  has  healed  all  efforts  are  in  order  to  guard  against 
recurrence.  Roller  bandages,  elastic  stockings,  massage,  local  and 
general  hygiene,  may  act  efficiently  in  this  connection.  Electro- 
therapy in  the  form  of  ionization,  combined  with  radiotherapy,  is 
very  serviceable  for  the  control  of  dermatosclerosis. 

Phagedenic  Ulcers  of  Tropical  Countries. — In  the  hot  and  moist 
climates  of  the  tropical  and  subtropical  zone  of  both  hemispheres, 
ulcers  of  as  yet  undetermined  character  have  been  observed,  which 
are  called  tropical  ulcer,  or  according  to  the  regions  where  they 
occur,  Annamite  ulcers,  Mozambique  ulcer,  malgache,  etc. 

It  is  more  than  probable  that  this  syndrome  comprises  altogether 
dissimilar  types  and  has  often  been  made  to  include  ulcerative 
syphilides,  chancrous  phagedenas,  leishmaniosis,  varicose  ulcers, 
etc.  Tropical  ulcer  is  usually  situated  in  the  lower  third  of  the  legs, 
or  on  the  dorsum  of  the  foot,  very  rarely  on  the  hands,  exceptionally 
elsewhere.  It  begins  as  a  papulopustule  which  becomes  gangrenous 
and  spreads.  It  has  rounded  or  oval  contours,  flat,  unthickened 
borders  and  often  a  concave  or  funnel-shaped  center. 

An  atonic  form  has  been  described ;  the  sometimes  very  extensive 
loss  of  substance  has  a  grayish,  diphtheroid  or  sanious  floor  and  a 
serpiginous  outline;  repair  is  delayed  a  long  time  and  recurrences 
are  common,  even  after  several  years. 

The  rapid,  phagedenic  or  gangrenous  form  is  extensive  or  per- 
forating and  advances  in  acute  attacks,  sometimes  associated  with 
fever;  the  ulcer  is  lined  with  soft  fetid  masses;  it  makes  deep  bur- 
rows, opens  tendon  sheaths  and  joints,  exposes  the  bones,  becomes 
complicated  by  lymphangitis  or  neuritis  and  gives  rise  to  mutilations 
and  fault)'  cicatrices.  After  a  certain  length  of  time,  it  may  become 
atonic. 

In  both  forms,  a  sensation  of  heat  and  sometimes  intolerable  pains 
are  present.  There  is  practically  no  tendency  to  spontaneous  cure, 
except  when  the  patient  moves  to  a  different  climate. 

Tropical  ulcer  is  observed  in  wretched  and  exhausted  individuals, 
weakened  by  alcohol,  malaria,  etc.,  especially  in  those  who  work 
with  bare  feet  in  water,  as  in  rice  plantations,  etc. 

The  starting-point  is  an  excoriation  or  a  wound,  the  bite  of  a 
leech,  or  mosquito,  a  pustule  of  ecthyma,  an  ulcerative  syphilide; 
briefly,  any  entrance  for  infectious  microorganisms. 

Tropical  ulcer,  although  only  slightly  contagious,  is  inoculable 
and  auto-inoculable;  animals  are  not  susceptible. 

A  variety  of  bacilli  have  been  described.  Le  Dantec  and  others 
had  observed  a  matting  of  bacilli;  Vincent  (1905)  showed  it  to  be 
caused  by  a  fusospirillary  association  (Spirocheta  schaudinni,  Prow- 
azek  1907),  thereby  proving  its  identity  with  hospital  gangrene 
and  ulcerative  membranous  stomatitis. 


302 


ULCER  A  TIONS  A  XD   ULCER  A  77  \  E   DER  MA  TOSES 


Treatment  con>ists  in  first  cleansing  the  ulcer  by  means  of 
washing  and  suitable  dressings,  dry  or  moist,  sometimes  assisted 
bj  curettage.  After  it  has  been  cleansed,  washing  with  a  zinc 
chloride  solution,  the  application  of  calcium  chloride  as  a  powder  or 
of  protargol  ointment  of  .">  to  20  per  cent.  (Castellani)  or  powdered 
arsenobenzol  is  in  order,  avoiding  caustic  agents  and  bland  powders. 
Intravenous  injections  of  arsenobenzol,  although  sometimes  remark- 
ably effective,  may  fail  unless  combined  with  good  local  treatment. 
In  all  cases,  absolute  resl  is  imperative  and  the  general  condition 
musl  be  improved  by  appropriate  measures. 


Fig.    10."). — Malum  perfori 
itated  Mm]. mat ii 


i    firsl    attack    \\1  ich    I  ad 
f  the  first  metatarsal. 


From  the  prophylactic  viewpoint,  it  i>  well  to  remember  that  in 
hot  eoi  nitric-,  all  wounds  including  the  most  trifling  abrasions*should 

l»c  carefully  Matched  and  dressed. 

Malum  Perforans.  This  name  has  been  given  to  ulcers  of  small 
dimensions  and  very  slow  course,  apparently  connected  with  a 
trophic  disturbance.  They  are  observed  in  adults  and  aged  indi- 
viduals, oftener  in  the  male  sex,  especially  in  the  course  of  tabes, 
sometimes  diabetes,  syringomyelia,  leprosy,  polyneuritis,  arterio- 
sclerosis ami  sometimes  without  a  demonstrable  cause. 


ULCERATIONS  OF  MUCOUS  MEMBRANES  303 

Malum  perforans  plantaris,  studied  by  Nelaton,  has  its  seat  of 
predilection  under  the  head  of  the  first  or  fifth  metatarsal,  or  at  the 
heel,  or  on  any  other  point  of  the  foot  exposed  to  pressure  (Fig.  105). 
There  are  sometimes  several  ulcers  and  both  feet  may  be  affected. 

The  disease  usually  begins  as  a  painful  corn,  a  rounded  hyper- 
keratosis on  which  blisters  are  repeatedly  formed,  or  as  a  small 
crust.  Before  long,  under  the  horny  covering  or  under  the  crust, 
a  rounded  ulcer  is  found,  with  a  proliferating  or  atonic  floor,  with 
perpendicular  walls  surrounded  by  hyperkeratosis.  It  burrows 
more  or  less  deeply,  and  may  reach  the  tendons,  joints  and  bones  and 
the  latter  when  examined  by  .r-rays  are  often  found  to  be  altered. 

This  lesion  is  painful  on  strong  pressure,  but  often  entirely 
anesthetic  to  needle-pricks  in  a  variable  radius. 

Cases  of  mal.  perforans  affecting  the  fingers  (malum  perforans 
digitalis),  the  back  of  the  foot,  the  nose  or  mouth,  which  may  be 
encountered  in  the  course  of  tabes,  as  well  as  mal.  perforans  of 
amputation-stumps,  are  very  rare.  They  consist  in  losses  of  sub- 
stance resembling  traumatic  abrasions,  but  occurring  spontaneously, 
painless  and  anesthetic,  often  symmetrical,  without  any  inflam- 
matory reaction  and  indefinitely  persistent.  Buccal  mal.  perforans 
is  often  preceded  or  accompanied  by  a  fall  of  teeth  and  frequently 
gives  rise  to  losses  of  bony  substance  through  absorption  or  seques- 
tration. 

The  treatment  of  mal.  perforans  plantaris  requires  rest;  the  horny 
masses  should  be  scraped  off  after  moist  dressings  or  a  salicylic 
acid  plaster  has  been  applied,  followed  by  curettage  or  cauterization 
of  the  ulcer.  The  wound  is  dressed  with  substances  favoring 
cicatrization. 

High  frequency  currents  have  seemed  to  me  to  be  very  efficient. 
In  tabetic  cases,  healing  is  not  infrequently  obtained  by  intravenous 
injections  of  arsenobenzol.  In  order  to  guard  against  recurrences, 
which  are  always  to  be  feared,  it  is  advisable  to  protect  the  region 
against  all  pressure  by  means  of  appropriate  dressings  or  special 
foot-gear. 

In  the  grave  cases  associated  with  suppuration  and  opening  of 
joints  or  bony  necrosis,  partial  amputations  are  sometimes  unavoid- 
able. 

ULCERATIONS  OF  MUCOUS  MEMBRANES. 

Although  a  comparison  of  the  ulcerations  of  the  various  mucosa 
would  be  extremely  interesting  from  the  diagnostic  point  of  view, 
the  subject  is  too  large  for  full  presentation.  I  shall  therefore  discuss 
only  the  buccal  mucosa  (excluding  the  isthmus  of  the  pharynx  and 
consequently  the  anginas)  and  the  genital  mucosa?.  On  the  other 
hand,  the  term  "ulceration"  will  be  used  in  its  widest  and  most 


304         ULCERATIONS  AX  J)   ULCERATIVE  DERMATOSES 

comprehensive  sense,  so  as  to  cover  the  most  superficial  epithelial 
abrasions  up  to  the  deepest  ulcers.  It  must  be  conceded,  however, 
that  completeness  is  almost  impossible  in  a  subject  of  this  kind. 

Buccal  Mucosa. — In  considering  an  ulceration  of  the  mouth,  all 
its  features  must  be  carefully  noted  by  the  physician,  but  with 
special  attention  to  the  following  points:  depth,  condition  of  the 
surface,  configuration,  base,  number,  site,  course.  Needless  to  say, 
the  diagnosis  will  usually  be  greatly  helped  by  the  general  exami- 
nation of  the  patient. 

1 .  Dry  Erosions  or  Depapillated  Plaques  of  the  Tongue. — When 
these  are  persistent  and  not  dependent  upon  a  stomatitis,  an  acute 
infectious  disease  or  a  gastric  disorder,  they  should  suggest  syphilitic 
smooth  plaques,  sclerotic  glossitis,  mild  leukoplakia  or  glossitis 
inarginata.  There  are  still  other  smooth  plaques  the  origin  of 
which  is  not  always  demonstrable. 

2.  Moist  and  Diphtheroid  Erosions. — All  vesicles  or  bullae  of 
mucous  membranes  are  very  rapidly  transformed  through  macera- 
tion and  loss  of  the  raised  epidermic  layer  into  erosions  which  are 
frequently  covered  with  a  pseudomembrane. 

Buccal  herpes  is  characterized  by  round  microcyclic  erosions, 
often  grouped  or  confluent,  rather  painful,  not  very  persistent. 
This  herpes  is  recurrent  in  certain  individuals. 

Buccal  zona,  which  is  extremely  rare,  is  said  to  be  unilateral  and 
non-recurrent. 

Artificial  bullae,  resulting  from  burns,  produced  by  a  cigar,  for 
example,  are  often  of  irregular  shape  and  obvious  localization. 

Hydroa  and  Duhring's  disease  are  accompanied,  in  about  one- 
half  of  the  cases,  by  buccal  lesions  on  the  inner  surface  of  the 
checks,  the  posterior  surface  of  the  lips,  the  palate,  sometimes  on 
the  tongue  or  on  the  isthmus  of  the  throat;  in  the  form  of  rounded 
or  superficially  confluent  bright  red  erosions  partly  covered  by  a 
membranous  or  diphtheroid  layer  and  extremely  painful.  The 
coexistence  of  the  cutaneous  eruption  reveals  their  true  character. 

Chronic  pemphigus  has,  on  the  contrary,  a  nearly  constant  and 
often  primary  buccal  localization;  it  may  remain  the  sole  mani- 
festation for  many  weeks. 

In  the  few  cases  which  have  come  under  my  observation,  the 
pillars  of  the  fauces,  the  pharynx,  the  cheeks  and,  later  on,  the  lips 
and  the  borders  of  the  tongue  presented  grayish  or  sanious,  friable 
or  adherent  false  membranes,  covering  partially  ulcerative  and 
oozing  erosions,  of  irregular  form  and  slowly  progressive  course. 
Objectively,  the  condition  suggested  diphtheria,  Vincent's  stoma- 
titis, a  medicinal  stomatitis,  or  even  syphilides.  The  pains  were 
intolerable,  the  odor  was  offensive,  the  glands  were  enlarged;  the 
general  condition  was  seriously  affected,  with  slight  fever,  but  very 


ULCERATIONS  OF  MUCOUS  MEMBRANES  305 

rapid  emaciation.  The  diagnosis,  rendered  probable  by  these  con- 
ditions and  by  the  presence  of  a  slight  bullous  elevation  at  the 
margin  of  the  erosions,  was  confirmed  by  the  appearance  of  blebs 
in  the  genital  region  and  on  the  fingers.  The  gravity  of  this  fearful 
disease  is  well  known. 

Syphilitic  mucous  patches  are  the  most  frequent  buccal  erosions 
and  ulcerations  and  those  which  it  is  most  important  to  know.  The 
general  description  and  that  of  the  principal  varieties  are  given  else- 
where in  this  book  (p.  620).  It  must  be  kept  in  mind  that  it  is  not 
justifiable  to  base  the  diagnosis  of  syphilis  simply  on  the  demon- 
stration of  lesions  presenting  the  appearance  of  mucous  patches, 
for  they  are  not  characteristic  in  themselves  (A.  Fournier);  the 
coincidence  of  other  manifestations  with  their  special  chronology 
is  required  or  the  demonstration  of  the  Spirocheta  pallida,  a  posi- 
tive Wassermann  reaction,  generalized  glandular  enlargements, 
etc. 

Syphilitic  chancre  is  ordinarily  erosive  on  the  tongue.  It  is  seen 
at  the  extreme  tip  of  the  organ,  in  the  form  of  a  fissured  erosion;  or  on 
the  dorsal  aspect  of  the  anterior  third,  in  the  form  of  a  lenticular 
or  oval,  pink  or  sometimes  grayish,  single  and  painless  eroded  spot. 
Very  careful  palpation  reveals  a  parchment-like  induration  at  its 
base;  the  corresponding  glands  always  assume  a  disproportionate 
enlargement  as  compared  to  the  apparent  importance  of  the  lesion ; 
they  are  non-inflammatory  and  painless;  occasionally,  the  glands 
are  the  first  to  attract  attention  and  point  to  the  initial  lesion.  On 
the  gums  the  chancre  is  likewise  merely  an  erosion,  frequently 
semicircular. 

Buccal  diphtheria  is  rarely  primary,  being  generally  secondary 
to  diphtheritic  angina.  It  consists  of  irregular  pseudomembranous 
adherent  patches,  located  on  the  lips  and  on  the  inner  surface  of 
the  cheeks.  The  Loefner  bacillus  is  found,  either  in  pure  culture  or 
in  varied  associations. 

Diphtheroid  stomatitis  is  of  frequent  occurrence  in  children; 
the  false  membrane  here  is  less  coherent;  it  is  apparently  often 
due  to  pyococci.  The  most  distinctive  form  is  impetigo  buccalis 
(impetiginous  stomatitis  of  Sevestre  and  Gaston),  the  features  of 
which  have  been  described  elsewhere. 

Thrush  (soor,  muguet)  is  not  an  ulcerative  lesion,  but  might  be 
confused  with  a  diphtheroid  erosion.  It  presents  the  appearance 
of  a  pure  white  or  creamy  adherent  layer  on  an  erythematous  base ; 
when  it  is  detached,  the  mucosa  is  seen  to  bleed.  Thrush  is  observed 
in  cachectic  individuals  and  in  little  children  suffering  from  digestive 
disturbances.  It  occurs  on  the  tongue,  the  cheeks,  the  isthmus,  in 
the  form  of  very  small  elevations  which  subsequently  become  con- 
fluent in  ragged  irregular  patches.  On  inspection  under  the  micro- 
20 


306         ULCERATIONS  AND   ULCERATIVE  DERMATOSES 

scope,  the  coating  is  shown  to  be  made  up  of  epithelial  debris  and 
very  abundant  filaments  of  endomyces  albicans. 

3.  Ulcerations.  In  whooping-cough  (pertussis)  of  children,  an 
ulceration  of  the  frenuni  of  the  tongue  is  observed,  caused  by  its 
rubbing  against  the  teeth  and  assisting  the  diagnosis  by  its  location. 
Other  simple  ulcers,  especially  of  traumatic  origin,  due  to  bites 
(as  in  epileptics)  or  to  friction  of  the  mucosa,  are  encountered  at 
any  age  on  the  border  of  the  tongue,  or  sometimes  on  the  inner 
surface  of  the  cheeks  or  the  lips,  notably  at  points  which  are  in 
contact  with  some  roughening  of  the  teeth,  due  to  dental  caries,  etc. 
These  ulcerations  are  deep,  of  irregular  shape  with  an  edematous  or 
sometimes  indurated  base,  painful  and  usually  without  glandular 
involvement.  They  heal  spontaneously  after  the  removal  of  the 
offending  tooth  or  roughness  and  disinfection  of  peridental  foci  of 
suppuration. 

Common  a  phi  ha-  are  small,  punctiform,  or  at  most  lenticular 
yellowish  ulcerations,  perfectly  round  or  oval,  following  upon  a 
grayish  vesicle  and  surrounded  by  a  characteristic  carmine-red 
narrow  border;  they  give  rise  to  a  very  painful  burning  sensation. 
They  are  seen  at  all  ages,  always  in  very  small  numbers,  but  these 
aphthae  may  come  and  go  for  a  long  time  in  dyspeptic  and  nervous 
individuals  following  errors  in  diet,  overexertion,  or  irritative  local 
causes  in  the  mouth.  The  co-existence  of  herpes  is  not  uncommon. 
Inflammatory  complications  are  rare. 

Common  aphthae  are  certainly  in  no  way  related  to  aphthous 
fever,  a  contagious  disease  of  bovine  origin,  apparently  trans- 
missible to  man  through  cows'  milk  [foot  and  mouth  disease]. 
According  to  certain  writers,  this  gives  rise  to  an  abundant  erup- 
tion of  aphthae  in  the  mouth,  together  with  serious  general  manifes- 
festations;  but  this  is  not  an  established  fact. 

The  ulcero-membranous  stomatitis  of  Rilliet  and  Barthez  and 
of  Bergeron,  which  is  now  considered  as  identical  with  Vincent's 
angina  and  stomatitis,  is  due  to  mixed  infection  with  the  fusiform 
bacillus  and  spirilla;  it  is  easy  to  demonstrate  these  parasites, 
which  are  seen  in  large  numbers  and  often  in  pure  cultures  on 
smears  of  the  exudate  stained  with  dilute  Ziehl's  solution  or  car- 
bolized  thionin. 

\  incent's  stomatitis  is  observed  particularly  in  children  and 
youthful  individuals,  especially  in  weakened  or  exhausted  persons, 
sometimes  in  almost  epidemical  form  in  crowded  places,  asylums, 
barracks,  etc.  |lt  was  quite  common  among  the  soldiers  in  the 
( rreal  War  and  was  known  as  trench  mouth. |  The  onset  is  followed 
Immediately,  or  after  a  few  days  of  fever,  malaise,  and  local  distress, 
by  salivation,  an  offensive  breath  and  pain. 

Inspection  of  the  mouth  shows  swollen  and  ulcerated  gums;  on  the 


ULCERATIONS  OF  MUCOUS  MEMBRANES  307 

cheeks,  especially  in  the  vicinity  of  the  last  lower  molar  tooth, 
then  on  the  entire  inner  surface  of  the  cheeks  and  sometimes  of 
the  lower  lip,  rounded  ulcerations,  or  a  sinuous  ulcerated  band, 
make  their  appearance.  The  lesions  often  invade  the  sides  of 
the  tongue,  sometimes  the  palate  and  the  velum  or  the  tonsils; 
in  some  cases  they  remain  unilateral  or  predominate  on  one  side. 

The  following  are  some  of  their  most  essential  features:  the 
floor  of  the  ulcers  is  grayish  or  the  color  of  wine-dregs,  usually 
masked  by  pultaceous,  sanious,  or  even  gangrenous  detritus;  per- 
pendicular borders;  a  non-indurated  base;  the  teeth  are  often 
bared  through  erosion  of  the  alveolar  margin ;  severe  pain  is  present ; 
mastication  is  impossible ;  there  is  profuse  salivation  and  a  peculiar 
disgusting  odor. 

The  submaxillary  glands  are  enlarged  and  painful;  the  expression 
of  the  face  is  drawn  and  pale;  there  is  well-marked  anorexia;  a 
slight  fever  may  be  present. 

When  left  untreated,  the  affection  may  last  during  several  weeks 
or  even  months;  by  proper  care,  it  can  be  cured  in  eight  to  fifteen 
days.     The  prognosis  is  on  the  whole  favorable. 

Syphilitic  chancre  of  the  mouth,  in  contradistinction  to  tonsillar 
chancre,  is  very  rarely  ulcerative. 

Ulcerative  secondary  syphilides  are  observed  in  the  ordinary 
forms  of  the  disease  as  well  as  in  precocious  malignant  syphilis  and 
are  characterized  by  their  sharp  outline  circular  form  and  by  the 
depth  of  the  lesion;  they  develop  rapidly. 

The  ulcerative  gummas  of  the  tongue  and  the  sclero-gummous 
idcerations  have  been  discussed  elsewhere. 

The  ulcerations  of  leukoplakia  deserve  special  mention.  In  the 
patches  on  1he  tongue,  as  well  as  on  the  cheeks  and  the  lips,  there 
are  frequently  encountered,  not  only  more  or  less  persistent  fissures, 
but  also  very  peculiar  chronic  ulcerations  which  do  not  seem  to 
have  attracted  the  attention  of  authors.  I  have  repeatedly  called 
attention  to  the  characteristics  of  these  leukoplasic  ulcers. 

Their  shape  is  irregular,  often  angular;  their  floor,  of  a  bright  red 
color,  smooth  or  finely  mammillated,  is  frequently  raised  on  a 
plane  up  to  the  level  of  the  borders,  from  which  it  is  separated  by 
a  deep  furrow  cut  out  as  if  with  a  knife  and  brought  into  view  by 
unfolding  it. 

Besides  being  a  source  of  annoyance,  obstinate  to  treatment  and 
frequently  recurrent,  these  ulcers  are  furthermore  alarming  because 
they  give  rise  to  the  dread  of  epithelioma;  it  is  reassuring  that  their 
base  is  not  more  indurated  than  that  of  the  neighboring  sclerotic 
surfaces.  In  my  opinion  they  are  due  to  a  local  nutritional  dis- 
turbance of  the  mucosa,  referable  to  the  underlying  sclerosis  and 
arteritis. 


308         ULCERATIONS  AND   ULCERATIVE  DERMATOSES 

In  order  to  cure  them,  recourse  must  be  had  to  calomel  injections, 
intravenous  injections  of  arsenobenzol,  or  to  local  mercurial  injec- 
tions of  weak  concentration.  Putting  the  teeth  in  good  condition 
and  proper  buccal  hygiene  are  indispensable.  I  regard  it  as  inad- 
visable to  irritate  these  lesions  by  caustic  agents,  but  have  often 
had  good  results  from  the  employment  of  radium  or  .r-rays. 

Trophic  ulcer,  malum  perforans  of  the  mouth,  has  been  observed, 
especially  in  tabetic  patients,  on  the  alveolar  margin  and  the  bony 


Tuberculous  ulcer  has  already  been  described.  I  repeat  that  the 
tongue  and  the  lips  are  among  its  seats  of  election. 

I  shall  not  dwell  upon  the  buccal  ulcerations  of  very  variegated 
appearance  which  occasionally  occur  in  the  stomatitides  of  uremia 
and  diabetes,  in  scurvy  and  other  severe  infectious  diseases  or  con- 
ditions leading  to  cachexia. 

Mercurial  stomatitis  is  probably  merely  a  special  instance  of 
Vincent's  spirillary  stomatitis.  In  its  milder  forms,  it  is  limited 
to  superficial  irregular  ulcerations,  covered  with  a  white  mass, 
situated  at  the  neck  of  the  last  molar  tooth  and  its  immediate 
neighborhood,  at  the  neck  of  the  lower  incisors  and  sometimes  on 
the  borders  of  the  tongue.  They  are  accompanied  by  profuse 
salivation,  a  diffuse  doughy  exudate  and  a  characteristic  fetid  odor. 
In  the  severe  forms,  however,  deep  gangrenous  ulcerations  have 
been  noted,  involving  the  checks,  the  gums,  or  even  the  bones  and 
sometimes  true  gangrene  of  the  tongue. 

Noma,  or  buccal  gangrene,  was  described  in  former  times  as 
rather  frequent  in  children  between  two  and  four  years  of  age, 
especially  as  a  sequel  of  measles  or  typhoid  fever,  sometimes  occur- 
ring in  epidemic  form. 

Noma  in  children  was  said  to  begin  as  a  livid  swelling  of  the 
cheek;  the  mucous  surface  presents  one  or  several  blisters,  covering 
livid  then  grayish  sloughs;  their  fall  leaves  an  ulceration  which 
rapidly  spreads  and  burrows,  with  ragged  margins  and  a  sanious, 
irregular,  horribly  offensive  floor,  sometimes  perforating  the  cheek. 
The  teeth  fall  out  and  the  bones  become  necrotic.  Death  supervenes 
in  four-fifths  of  the  cases,  in  eight  to  fifteen  days. 

The  condition  in  all  probability  represented  an  ulcero-membran- 
ous  stomatitis,  due  like  hospital  gangrene  to  a  fuso-spirillary  infec- 
tion. The  very  grave  eases  to  which  the  above  description  is 
applicable  have  fortunately  become  extremely  rare. 

In  the  tropics,  among  half-famished  and  improvident  natives, 
cases  of  extensive  gangrene  of  the  lips  and  cheeks  are  observed, 
suggestive  of  noma  and  perhaps  referable  to  the  same  etiology, 
but  more  probably  the  result  of  phagedena  of  various  kinds. 


ULCERATIONS  OF  MUCOUS  MEMBRANES  309 

4.  Ulcerative  Neoplasms. — In  the  cases  of  tuberculo-ulcerative 
syphilide  of  the  buccal  cavity,  or  in  the  less  common  cases  of  ulcer- 
ated lupus  of  the  buccal  mucosa,  it  is  readily  seen  that  the  ulcera- 
tions are  not  primary,  but  develop  on  a  neoplastic  patch  having  the 
features  described  above.  They  are  generally  multiple,  rounded, 
perpendicular,  with  a  relatively  hard  base  in  case  of  syphilis; 
irregular,  less  deep,  with  soft  borders,  in  case  of  lupus. 

Epithelioma  of  the  buccal  cavity  is,  in  the  great  majority  of  the 
cases,  of  the  lobulated  types.  I  have,  however,  seen  numerous 
instances  of  tubular  [basal-celled]  epithelioma. 

In  the  great  majority  of  cases,  epithelioma  is  situated  on  the 
tongue  or  on  the  lips,  sometimes  on  the  cheeks,  the  pharynx,  the 
palate,  the  gums,  the  floor  of  the  mouth.  It  begins  under  the 
papillary  form,  or  as  a  fissure,  as  I  have  pointed  out  in  connection 
with  leukoplakia,  and  also  as  a  discoid  elevation  from  the  start. 
It  becomes  eroded  very  soon  and  then  excavated  by  an  ulceration. 

The  characteristics  of  epitheliomatous  ulcer  are  as  follows: 
Almost  invariably  irregular  shape;  very  uneven,  proliferating, 
sanious,  readily  bleeding  floor,  sometimes  interspersed  with  small 
yellowish  or  gray  masses;  raised,  swollen  or  overhanging  borders  in 
lobulated  epithelioma,  perpendicular  borders  in  the  tubular  form; 
the  base  is  always  indurated,  forming  the  tumor.  Glandular 
enlargement  occurs  early  in  lobular  epithelioma  and  determines 
an  unfavorable  prognosis;  it  is  absent  or  very  much  delayed  in  the 
tubular  variety. 

Actinomycotic  ulcer  of  the  mucosa  has  the  same  characteristics 
as  in  the  skin.  Yellow  granules  can  be  extracted  from  it.  The 
reader  is  referred  to  Chapters  XXVIII  and  XXIX  for  the  buccal 
ulcerations  of  the  sporotrichoses,  leishmaniosis,  etc. 

Other  tumors,  notably  the  sarcoma  known  as  epulis,  or  even 
benign  neoplasms,  may  become  accidentally  ulcerated. 

Treatment  of  Buccal  Ulcerations. — In  a  general  way,  much  can  be 
accomplished  by  scrupulous  hygiene  for  the  prevention  of  ulcera- 
tions of  the  buccal  mucosa.  Prophylactic  treatment  consists  in 
proper  care  of  the  teeth  and  gums;  the  mechanical  removal  of 
tartar,  cleansing  and  filling  of  carious  cavities,  extraction  of  stumps, 
cauterization  of  fungoid  or  soft  gums  and  adjustment  of  prosthetic 
apparatus,  should  be  left  to  the  dentist.  The  results  achieved 
must  be  maintained  by  regular  brushing  with  a  soapy  powder  or 
paste  or  any  good  dentifrice. 

These  measures  are  positively  required  in  syphilitics,  from  the 
beginning  of  mercurial  treatment,  in  patients  recovering  from  severe 
infections,  in  persons  predisposed  to  herpes,  aphtha?,  etc.  In 
addition  there  should  be  abstinence  from  tobacco,  alcoholic  bev- 
erages and  irritating  food. 


310      ulcerations  and  Ulcerative  dermatoses 

As  to  curative  treatment,  only  brief  suggestions  can  here  be 
offered.  Erosions,  opaline  mucous  patches  and  aphthae  are  bene- 
fited by  superficial  silver  nitrate  cauterizations  every  second  or 
third  day;  irrigations  with  dilute  peroxide  water  or  potassium 
chlorate.  Soothing  mouth  washes  are  sufficient  in  cases  of  acute 
irritation.  Mechanical  cleansing  with  a  wisp  of  cotton  wet  with 
alkaline  or  horated  solution  will  suffice  in  thrush. 

The  ulcerations  of  ulcero-membranous  stomatitis  are  treated  with 
mouth-baths  of  dilute  Labarraque's  solution,  1  to 20;  cleansing  with 
a  small  stick  wrapped  in  cotton,  followed  by  touching  with  silver 
nitrate;  with  powdered  arsenobenzol,  calcium  chloride  in  substance, 
powdered  methylene-blue  or  iodine  tincture.  Internally,  sodium 
chlorate,  grams  2  per  diem,  is  recommended.  Intravenous  injec- 
tions of  arsenobenzol  are  efficient  only  when  combined  with 
proper  local  treatment.  [It  is  the  method  of  choice  in  Vincent's 
infection.]  It  is  highly  advantageous  to  apply  to  syphilitic  ulcers, 
together  with  the  indispensable  general  treatment,  the  various 
topical  agents  enumerated  above.  The  treatments  suitable  for 
the  other  cases  have  been  discussed  elsewhere. 

Genital  Mucosae. — The  majority  of  the  erosive  or  ulcerative 
affections  occurring  in  the  mouth  may  also  be  encountered  on  the 
genital  mucosa?  or  semimucosse  of  both  sexes. 

This  is  especially  true  of  herpes,  which  is  common  in  this  location; 
of  syphilitic  manifestations  of  all  kinds  and  of  hydroa;  on  the  other 
hand,  aphthae,  impetigo,  thrush  and  diphtheria  are  rare.  Again, 
localizations  of  various  dermatoses  are  here  met  with,  which  do 
not  occur  in  the  mouth,  such  as  eczema,  psoriasis,  eczematides, 
scabies  and,  furthermore,  a  few  special  erosions  and  ulcerations. 

Traumatic  excoriations  due  to  coitus,  scratching  with  the  finger- 
nails, rape,  etc.,  often  have  a  characteristic  irregular  or  fissured 
form;  unless  complicated  by  a  superadded  affection  they  heal  with 
remarkable  rapidity. 

Soft  chancre  has  been  sufficiently  emphasized  and  does  not  require 
further  discussion. 

Gonorrhea  gives  rise,  in  men,  to  a  more  or  less  acute  diffuse 
balanoposthitis,  sometimes  with  phimosis  and  ordinary  or  follicular 
erosions  at  the  base  of  the  glans  and  in  the  sulcus.  Gangrene 
of  the  prepuce  in  these  cases  is  very  rare. 

In  women,  gonococcal  vulvitis  may  be  accompanied  by  small 
para-urethral  follicular  ulcerations,  by  canaliculitis ,  namely  inflam- 
mation, sometimes  ulcerative,  of  the  excretory  duct  of  Bartholin's 
gland,  sufficiently  characterized  by  its  seat;  finally,  by  gonococcal 
erosions  of  a  dusky  red,  granular  surface,  distinct  or  jagged  margins, 
localized  especially  outside  of  the  caruncuhe  myrtiformes.  Being 
frequent  and  very  persistent,  these  lesions  may  at  the  first  glance 


ULCERATIONS  OF  MUCOUS   MEMBRANES  311 

betray  the  existence  of  gonorrhea,  which  the  patient  is  endeavoring 
to  conceal. 

Diabetes  gives  rise  not  only  to  erythematous,  eczematous,  etc., 
balanoposthitis  and  vulvitis,  but  also  to  fissures  and  ulcerations 
of  very  variable  aspect,  syphiloid  in  appearance,  and  even  to 
gangrenes. 

Circinate  erosive  balanoposthitis  manifests  itself  in  the  form  of 
extensive  polycyclic,  superficially  erosive  lesions  bordered  by  a 
narrow  white  margin.  This  affection,  attributed  to  spirilla  by 
Berdal  and  Bataille,  was  recognized  by  Queyrat  as  a  localization 
of  the  fuso-spirillary  symbiosis  which  also  causes  Vincent's  stoma- 
titis. An  analogous  affection  may  be  met  with  in  women.  In 
neglected  cases,  circinate  balanitis  lasts  several  weeks  and  is  often 
recurrent.  It  is  very  easily  cured  by  cleanliness  and  painting  with 
a  1  to  30  solution  of  silver  nitrate. 

Syphilitic  chancre,  the  different  varieties  of  secondary  syphilides 
or  mucous  patches,  and  the  tertiary  syphilides  of  the  genitals  have 
served  for  the  descriptions  of  the  manifestations  which  I  have  already 
given. 

Tuberculosis  may  manifest  itself  in  the  same  regions,  although 
this  is  very  rare,  as  tuberculous  ulcer,  resulting  from  a  contagion 
or  auto-inoculation  and  as  ulcerated  lupus,  which  is  still  more 
rare. 

Under  the  name  of  esthiomene,  introduced  by  Huguier  in  1848,  a 
rare  syndrome  is  still  occasionally  described,  which  is  character- 
ized by  a  chronic  ulceration  of  the  vulva  associated  with  elephan- 
tiasis. The  more  or  less  deep  and  often  painless  ulcer  is  situated 
at  any  point  of  the  vulva,  preferably  at  the  entrance  of  the  vagina. 
The  sometimes  enormous  hypertrophy  involves  the  labia  minora, 
the  clitoris,  the  labia  majora,  the  perineal  region,  etc. 

It  is  more  than  likely  that  the  nature  of  the  ulcer  is  very  different 
in  different  cases,  so  that  there  may  be  tuberculous  or  lupus  ulcers 
(Bernutz,  Ficquet),  soft  chancres  of  low  virulence  (Jacobi),  ulcera- 
tive tertiary  syphilides,  analogous  with  anorectal  syphiloma,  or  even 
epitheliomas,  which  as  a  result  of  local  conditions,  notably  a  lack 
of  cleanliness,  become  infected  and  give  rise  to  sclerogenic  inflam- 
matory edema.  [An  ulcerated  infected  lymphangioma  of  the  vulva 
may  produce  a  similar  picture.]  It  has  recently  been  pointed  out 
that  the  clinical  picture  of  esthiomene  is  perfectly  reproduced  in 
the  ulcerative  granuloma  of  the  genital  organs. 

Ordinary  secondarily  infected  wounds  or  excoriations  may  finally 
suffice  for  the  production  of  this  pathological  type,  as  a  sequel  of 
lymphangitis,  sclerosis,  or  removal  of  the  inguinal  glands,  etc. 
Esthiomene  would  in  this  way  become  entirely  comparable  to 
ulcer  of  the  leg  with  elephantiasis  nostras. 


312         ULCERATIONS  AND    ULCERATIVE  DERMATOSES 

Treatment  of  Genital  Ulcerations. — No  matter  what  may  be  the 
cause  and  character  of  a  balanoposthitis,  phimosis  or  vulvitis,  it 
is  of  great  importance  to  keep  the  parts  as  clean  as  possible.  If 
the  glans  cannot  be  uncovered  for  the  irrigations,  on  account  of  the 
existing  pain  and  inflammation,  injections  must  be  introduced  into 
the  subpreputial  sack  by  means  of  a  flexible  rubber  nozzle,  begin- 
ning with  lukewarm  cleansing  injections  with  large  amounts  of 
water,  followed  by  astringent  injections  with  a  1  :  100  silver  nitrate 
solution,  for  example,  or  dilute  peroxide  water. 

Exposed  erosions  or  ulcerations  are  treated  by  touching  them  with 
silver  nitrate,  tincture  of  iodine,  etc.,  with  bland  non-fermentable 
mineral  or  medicated  powders  or  finally  with  salves  or  creams. 

Keeping  in  mind,  however,  that  cauterizations  and  numerous 
topical  agents  produce  an  induration  which  may  become  misleading, 
these  should  not  be  employed  unless  the  diagnosis  is  already  quite 
positive. 

In  women,  it  is  necessary  to  emphasize  the  manner  in  which  the 
irrigations  are  to  be  used  so  as  to  be  really  efficient.  It  is  often 
advantageous  to  prevent  mutual  contact  between  the  parts,  by 
inserting  gauze  or  cotton  tampons  freely  dusted  with  powders  or 
covered  with  a  layer  of  zinc  ointment. 

In  case  of  important  or  serious  genital  ulcerations,  notably  those 
of  gangrenous  appearance,  the  surfaces  must  be  cleansed  by  local 
baths,  moist  dressings,  washing  with  peroxide  water  or  camphor- 
ated alcohol;  next,  iodoform  powder  may  be  applied,  with  a  little 
salicylic  acid  or  camphor,  or  according  to  the  case,  calcium  chloride, 
balsam  of  Peru,  etc. 

Needless  to  say,  all  necessary  directions  must  be  given  for  the 
avoidance  of  contagion. 

CUTANEOUS    GANGRENE. 

Cutaneous  gangrene  means  mortification  or  death  of  a  portion  of 
the  integument  and  may  be  accompanied  by  the  same  changes  in 
the  underlying  tissues.  When  it  is  abrupt  and  complete  from  the 
onset,  it  is  named  necrosis;  when  it  results  from  a  progressive  loss 
of  tissue  vitality,  it  is  called  necrobiosis;  this  distinction  is  of  small 
importance,  the  two  processes  being  frequently  combined.  The 
"dead"  portion  is  known  as  a  slough  or  .sphacelus.  It  is  distin- 
guished as  dry  gangrene  and  moist  gangrene,  according  to  its  being 
dry  and  mummified,  or  on  the  contrary,  moist,  putrefying  and  fetid. 

Gangrene  manifests  itself  as  a  change  in  color  of  the  skin,  which 
at  the  same  time  becomes  cold  and  anesthetic  to  touch,  pricking, 
and  temperature.  In  the  case  of  dry  gangrene,  the  skin  is  yellow 
or  purple,  then  brownish,  and  promptly  hardens  through  desicca- 


CUTANEOUS  GANGRENE  313 

tion,  becoming  depressed  below  the  normal  level.  Moist  gan- 
grene often  begins  as  a  purulent  bulla,  or  rather  as  a  bulla  with 
sanious  or  hemorrhagic  contents,  the  floor  of  which  becomes  necrotic ; 
or  a  flabby,  mottled,  grayish  surface  may  on  the  next  day  become 
covered  with  sanious  blebs. 

While  sometimes  unnoticed  by  the  patient,  the  process  in  other 
cases  is  preceded  or  accompanied  by  stiffness,  tingling,  heat  and 
intolerable  laminating  or  tearing  pains. 

After  a  few  days,  unless  the  necrosis  proceeds  very  rapidly,  the 
slough  becomes  surrounded  by  a  congestive  halo,  sometimes  bul- 
lous at  its  periphery;  on  the  line  of  demarcation  between  the  dead 
and  the  living  tissue,  a  deep  groove  is  formed  which  suppurates  more 
or  less  freely.  Having  become  dark  brown  or  black,  the  sphacelus 
retracts  and  is  finally  cast  off,  exposing  an  ulceration  covered  with 
detritus,  or  sometimes  pink  and  proliferating. 

The  pathogenic  mechanisms  to  which  the  various  forms  of  cutane- 
ous gangrene  are  due,  are  multiple.  In  each  particular  case,  there 
is  reason  to  look  for  one  or  several  of  the  following  conditions,  which, 
moreover,  instead  of  excluding  one  another  are  very  frequently 
associated : 

A.  Direct  local  action  of  a  mechanical,  physical  or  chemical 
necrotizing  agent. 

B.  Suppression  of  the  blood  supply  (through  embolism,  arteritis, 
etc.). 

C.  Serious  alteration  of  the  blood  itself. 

D.  Necrotizing  infection. 

E.  Serious  change  of  the  trophic  nerve  supply. 

The  last-named  factor,  often  emphasized  in  the  past  (Zambaeo, 
1859),  is  at  present  considered  as  altogether  accessory.  Neuro- 
trophism  may  sometimes  perhaps  act  as  a  favoring  factor,  but  the 
existence  of  trophic  gangrene  or  necrosis  of  trophic  origin  cannot 
be  admitted.  So-called  hysterical  gangrene  is  always  artificially 
induced. 

The  pathogenic  mechanism  from  which  certain  secondary  gan- 
grenes are  derived,  for  example  those  which  sometimes  complicate 
erysipelas,  anthrax,  soft  chancre,  etc.,  or  which  originate  in  malig- 
nant tumors,  cancers,  sarcomas,  the  tumors  of  mycosis  fungoides,  etc., 
is  probably  complex  and  cannot  always  be  definitely  established. 

A.  Direct  Local  Gangrene. — This  results  from  an  injury  directly 
affecting  the  mortified  point.  Traumatic  gangrene,  as  a  sequel  of 
crushing,  severe  contusions,  war-wounds,  belongs  to  the  domain  of 
surgery.  Prolonged  compression,  for  example  by  a  very  tight  plaster 
apparatus,  may  produce  a  direct  slough  or  ulceration. 

Decubitus  may  have  the  same  effect  on  the  compressed  points, 
especially  the  sacral  region  and  the  trochanteric  regions,  much  more 


314        ULCERATIONS  AND   ULCERATIVE  DERMATOSES 

rarely  the  heels  or  the  scapular  regions,  in  patients  whose  nutrition 
is  seriously  impaired  and  whose  vascular  tension  is  lowered  by  a 
severe  general  disease  or  a  disease  of  the  nervous  system  (dementia, 
myelitis,  hemiplegia,  etc.). 

The  sloughs  of  decubitus  [bed-sores],  which  were  formerly  con- 
sidered as  of  trophic  origin,  are  really  due  to  the  chronic  irritation 
of  the  integument  by  contact  with  the  urine,  fecal  matter,  and  cuta- 
neous secretions,  in  very  weakened  or  hypersensitive  individuals, 
with  secondary  infection  of  the  macerated  and  excoriated  skin. 
They  can  generally  he  avoided  by  extreme  cleanliness,  aseptic 
powders,  and  the  employment  of  air-cushions. 

Physical  causes,  such  as  burns,  frost-bite,  contact  with  continuous 
current  electrodes,  high  frequency  -park-,  ar-rays  in  excessive  doses, 
will  produce  gangrenous  patches  at  the  damaged  point-. 


Fig.    106. — Carbolic  gangrene  of  the  thumb,  in  a  child  aged  five  years,  who  had  worn 
a  carbolic  acid  dressing  during  one  night,  for  a  scratch  made  by  a  cat. 

Numerous  chemical  agents,  so-called  "caustics,"  notably  strong 
alkali-  and  acids,  certain  -alt-,  corrosive  sublimate,  zinc  chloride, 
etc.,  will  do  the  same.  Sometimes,  iodine  tincture  and  even  mus- 
tard plasters  may  produce  sloughs,  especially  in  children. 

Carbolic  gangrene  \>  entitled  to  special  mention,  on  account  of  its 
relative  frequency  and  its  insidious  behavior.  It  is  noteworthy  that 
the  total  loss  of  a  finger  ha-  repeatedly  followed  upon  a  simple 
panaris  or  whitlow,  dressed  with  a  solution  of  carbolic  acid,  even  in 
supposedly  harmless  dilutions  (Fig.  L06).  The  patient  is  not  warned 
by  any  painful  sensation  of  the  impending  gangrene.  It  is  therefore 
advisable  to  discard  carbolic  acid  dressings,  especially  for  the 
extremities. 

In  the  direct  gangrenes,  the  injurious  factor  usually  acts  at  the 
same  time  on  the  tis>ue  constituents  themselves  and  by  producing 


C  U  TA  NEO  US  GA  NO RENE 


315 


stasis  or  thrombosis  in  the  capillary  bloodvessels.    Infection,  when 
present,  is  superadded. 

B.  Gangrene  of  Vascular  Origin. — Any  portion  of  the  organism 
in  which  the  circulation  of  the  blood  is  completely  and  permanently 
arrested,  inevitably  undergoes  necrobiosis  or  necrosis.  The  venous 
system,  which  is  rich  in  anastomoses,  is  rarely  affected;  gangrenes 
in  the  course  of  phlebitis,  or  of  phlegmasia  alba  dolens,  being  of 
exceptional  occurrence.  Almost  invariably,  the  obliteration  is 
arterial,  affects  the  extremities,  and  the  gangrene  is  of  the  dry  type. 
Vascular  rupture,  sometimes  ligature,  compression,  embolism, 
especially  thrombosis  through  acute  or  chronic  arteritis,  produce 
different  forms  of  progressive  gangrene  of  the  extremities. 


Fig.   107. — Dry  symmetrical  gangrene  of  the  toes. 


These  gangrenes  are  observed  especially  on  the  feet,  beginning 
with  one  or  several  toes,  attacking  at  once  the  skin  and  the  deep 
tissues,  including  the  bones;  hence  they  do  not  belong  to  the  domain 
of  dermatology.  Only  the  principal  types  are  here  mentioned: 
Senile  gangrene;  gangrene  due  to  obliterative  endarteritis  of 
Friedlander  (Fig.  107) ;  gangrene  due  to  syphilitic  arteritis  [to  endo- 
phlebitis  migrans,  Buerger];  gangrene  in  typhoid  fever,  etc. 

Gangrene  of  the  extremities,  as  a  rule,  partial  or  limited  to  the 
fingers  or  toes,  which  occurs  in  the  grave  forms  of  Raynaud's  dis- 
ease, is  preceded  by  attacks  of  "  local  asphyxia"  and  "  local  syncope" ; 
it  has  been  attributed  to  a  vascular  spasm,  a  mechanism  which  would 


316         ULCERATIONS  AND   ULCERATIVE  DERMATOSES 

probably  be  incapable  of  producing  this  result.  Its  pathogenesis 
is  not  known.  The  rare  cases  of  gangrene  observed  in  progressive 
scleroderma  may  be  compared  with  it. 

C.  Gangrenes  Through  Changes  of  the  Blood.  —Under  this  head- 
ing I  group  the  toxic  gangrenes  and  those  gangrenes  which  may  be 
considered  as  autotoxic. 

Ergot  of  rye  gave  rise  in  the  middle  ages  to  epidemics  in  which 
the  general  phenomena  of  ergotism  were  associated  with  tingling 
sensations  or  severe  pains  and  mutilating  gangrenes  of  the  extremi- 
ties. 

Carbon  monoxide  poisoning  is  capable  of  producing  gangrene  in 
large  patches,  or  involving  an  entire  extremity.  Chloral,  when 
administered  for  a  long  time  and  in  large  doses,  has  been  accused  of 
the  same  effects.  The  question  of  gangrenes  in  the  course  of  Bright's 
disease,  which  are  rather  exceptional,  is  not  well  understood. 

Diabetic  gangrene,  on  the  contrary,  is  not  uncommon.  It  is 
observed  in  individuals  who  are  by  no  means  cachectic,  even  in  the 
enjoyment  of  excellent  health  and  without  large  amounts  of  sugar  in 
the  urine.  Assuredly  neither  hyperglycemia  nor  neuritis  nor  even 
arteritis  can  be  held  responsible,  except  perhaps  in  the  massive 
forms.  A  slight  traumatism  or  an  accidental  cutaneous  affection 
often  serves  as  determining  cause.  The  principal  part  is  probably 
referable  to  a  local  infection,  streptococcic  or  other,  or  to  septic 
embolisms. 

Massive  diabetic  gangrene  may  abruptly  attack  an  extremity, 
an  entire  limb,  the  genital  organs,  etc.  In  other  cases,  gangrenous 
patches  are  scattered  over  the  feet,  the  lower  limbs,  or  elsewhere,  in 
the  form  of  grayish  or  brown  sloughs,  preceded  by  a  blister  and  pro- 
gressively extensive.  In  this  form — named  bullo-serpiginous,  by 
Kaposi — the  center  may  heal  while  a  bullous  elevation  at  the  periph- 
ery marks  the  zone  of  invasion.  The  course  is  rapid  or  on  the 
contrary  very  sluggish.  The  prognosis  in  a  general  way  is  not  very 
unfavorable. 

When  gangrene  in  diabetics  is  secondary  to  suppurative  lesions, 
furuncles,  carbuncles,  abscess,  etc.,  the  symptoms  of  reaction  may 
be  mild,  although  the  situation  is  really  threatening. 

D.  Gangrenous  Infections. — Infection  through  bacteria  of  various 
kinds,  ordinary  or  special,  aerobes  or  perhaps  especially  anaerobes, 
plays  a  considerable  part  in  the  origin  and  in  the  course  of  cutaneous 
gangrenes. 

It  seems  logical,  a  priori,  to  group  under  two  separate  headings: 
(1)  Secondary  infected  gangrenes,  in  which  a  lesion  or  affection  of 
the  skin,  of  definite  character  (wounds,  ecthyma,  furuncle,  erysipelas, 
pemphigus,  varicella,  zona,  syphilide,  soft  chancre,  etc.),  becomes 
gangrenous  through  the  effect  of  an  excessive  virulence  of  its  causa- 


CUTANEOUS  GANGRENE  317 

tive  agent,  a  diminished  resistance  of  the  organism,  or  the  introduc- 
tion of  necrotizing  germs  from  the  outside;  (2)  primary  infectious 
gangrenes,  resulting  from  microbic  embolism  in  the  skin  by  the 
hematogenous  route.  Sometimes,  the  direct  examination  of  the 
patient  or  the  history  will  show  at  first  sight  that  the  case  belongs 
to  one  or  the  other  of  these  groups;  in  other  instances,  there  remains 
a  doubt. 

There  is  little  advantage  in  dwelling  upon  the  secondary  or  acci- 
dental infectious  gangrenes.  I  shall  therefore  discuss  only  those 
which  are  primary  and  essential;  leaving  aside,  of  course,  the  gan- 
grenes of  the  classified  general  diseases,  such  as  anthrax,  bubonic 
plague,  etc.,  and  discussing  instead  the  clinical  forms  of  dermato- 
logical  character. 

Multiple  Gangrene  of  Children. — This  is  a  somewhat  unusual 
clinical  type,  comprising  positively  dissimilar  forms,  such  as  those 
cases  which  have  been  described  under  the  names  of  multiple 
cachectic  gangrene  of  the  skin  (O.  Simon  and  Eichhof),  gangrenous 
dermatitis  of  children,  gangrenous  varicella,  gangrenous  ecthyma, 
gangrenous  urticaria,  purpura  fulminans,  etc. 

Instances  have  been  observed  in  very  young  children,  especially 
girls,  and  in  weakened  individuals.  Sometimes,  the  impression  of 
a  special  disease  is  conveyed;  in  other  cases,  one  is  apparently  con- 
fronted with  an  extraordinarily  malignant  form  of  an  exanthem 
(varicella,  vaccinia,  measles)  or  of  a  pseudo-exanthema  (purpura, 
polymorphous  erythema) . 

In  a  few  days,  a  more  or  less  abundant  eruption  of  erythematous, 
urticarial  or  purpuric  spots  makes  its  appearance,  or  there  may  be 
bullae  containing  a  reddish  serous  fluid,  or  pustules,  which  enlarge 
and  multiply.  Their  center  very  promptly  turns  black;  the  slough, 
concealed  or  not  by  a  crust,  spreads  more  or  less,  then  becomes 
surrounded  by  a  suppurative  groove  and  loosens,  leaving  a  per- 
pendicular or  dome-shaped  ulceration  with  a  sanious  floor.  The 
coalescence  of  several  lesions  gives  rise  to  festooned  patches.  The 
sloughing  may  destroy  a  portion  of  the  nose,  of  the  lips,  of  the  lobe 
of  the  ear,  of  the  external  genitals,  or  of  the  fingers  and  toes.  Nodosi- 
ties, edemas  and  abscesses  may  also  be  met  with. 

The  eruption  is  situated  especially  on  the  lower  portion  of  the 
trunk  and  on  the  thighs;  it  has  another  site  of  election  on  the  neck, 
on  the  scalp,  and  on  the  face;  but  it  may  be  widely  disseminated. 

The  general  symptoms  are  of  very  variable  severity,  sometimes 
only  slightly  marked;  but  often  the  condition  is  associated  with  a 
high  fever,  digestive  disturbances,  prostration,  convulsions,  as  well 
as  visceral  complications  leading  to  death;  the  mortality  is  about 
50  per  cent.    In  favorable  cases,  recovery  is  rapid. 

Numerous  pyococci  and  bacilli  have  been  held  responsible.    In 


318 


ULCERATIONS   AND    ULCERATIVE   DERMATOSES 


the  carefully  studied  case  of  Veillon  and  J.  Halle,  the  pathogenic 
agent  was  the  bacillus  ramosus;  it  is  probable  that  other  anaerobic 
microbes  may  produce  analogous  phenomena.  Recently  a  few  eases 
could  be  referred  to  the  meningococcus. 

Multiple  Gangrene  of  Adults.  No  discussion  is  here  called  for  of 
the  gangrenes  with  multiple  foci,  accompanied  by  abscesses  and 
gangrenous  phlegmons,  which  occur  in  rare  instances  in  the  course 
of  pestilential  diseases,  very  advanced  cachexias  and  severe  diseases 
of  the  nervous  system.  These  arc  cases  of  septic  embolisms  with 
anaerobic  microbes,  of  genuine  metastases,  derived  from  a  bed-sore 
or  a  gangrenous  focus  of  any  kind,  especially  a  pulmonary  gangrene. 


Fig.   ids 


Multiple  gangrene  of  adults;  of  filteen  days'  standing,  in  a  man  aged 
seventy-one  years  in  good  health. 


However,  gangrenous  eruptions  entirely  analogous  to  those  of 
children,  are  also  encountered  in  youthful  individuals,  in  good 
health  or  slightly  weakened  and  even  in  adults  of  middle  age.  They 
have  the  same  onset,  the  same  local  symptomatology,  the  same 
genera]  symptoms  ami  develop  in  successive  attacks.  Examples 
have  been  quoted  by  Doutrelepont,  Hallopeau,  Carle,  Brocq.  1 
have  personally  observed  several  rather  dissimilar  cases,  some  with 
multiple  patches  limited  to  a  single  region  (Fig.  ION),  others  with 
very  numerous  lesions  scattered  over  the  entire  integument.  The 
prognosis  is  grave,  although  not  necessarily  fatal.  Mention  has  been 
made  of  possible  contagiousness  1 1  >emme). 


CUTANEOUS  GANGRENE  319 

Fulminating  Gangrene  of  the  Genital  Organs. — A.  Fournier  has 
pointed  out  a  rare  type  of  gangrene,  observed  especially  in  young 
adults,  leading  to  grave  mutilations,  sometimes  to  death. 

Usually  as  the  result  of  a  slight  excoriation,  there  suddenly 
develops,  without  paraphimosis,  an  enormous  rose-colored  edema 
of  the  penis  and  scrotum,  with  chills,  high  fever,  etc.  At  the  end 
of  twenty-four  to  thirty-six  hours,  the  penis  after  having  assumed 
the  appearance  of  a  large  "clapper,"  presents  purplish,  black  or 
white  gangrenous  patches,  which  may  destroy  the  entire  sheathes, 
often  the  scrotum  and  rarely  the  corpora  cavernosa;  the  swelling- 
subsides  at  the  end  of  about  a  week. 

A  very  virulent  streptococcus  has  been  found  in  the  serous  dis- 
charge.   These  are  probably  cases  of  gangrenous  erysipelas. 

Treatment. — All  cutaneous  gangrenes  are  difficult  to  treat. 
Hygiene  and  general  medications  must  not  be  too  much  relied  on; 
even  in  the  cases  of  diabetic  gangrene,  where  a  strict  diet  is  impera- 
tive, this  cannot  prove  sufficient  by  itself  alone. 

Locally,  it  is  essential  to  supervise  scrupulous  cleanliness  and  well- 
applied  protective  dressings.  In  some  cases,  moist  aseptic  dressings 
are  useful,  or  the  application  of  dilute  peroxide  water,  or  even  pro- 
longed local  baths;  but  as  a  rule,  dry  or  oily  dressings  are  preferable. 
Dressings  with  strong  antiseptics  are  frequently  injurious. 

The  parts  may  be  swabbed  with  camphorated  alcohol,  or  with  a 
weak  solution  of  potassium  permanganate,  followed  by  wrapping 
in  dry  sterilized  cotton;  or  large  quantities  of  aseptic  or  weakly 
antiseptic  powders  may  be  used  (quinine,  iron  subcarbonate,  der- 
matol,  iodoform).  Oily  dressings,  with  carron-oil,  guaiacolized  oil, 
etc.,  are  often  better  liked  and  seem  to  act  more  favorably. 

When  the  gangrene  is  progressive  it  may  be  of  vital  importance  to 
destroy  the  focus  of  putrefaction  and  the  neighboring  zone  of  inva- 
sion. This  is  accomplished  by  applications  of  superheated  air  in 
jets  under  pressure;  this  requires  special  apparatus,  experience  and 
skill,  but  actually  constitutes  the  best  treatment  against  extensive 
gangrenes,  diabetic  as  well  as  others.  The  hot-air  method  is  prefer- 
able to  surgical  removal,  which  will  only  be  called  for  after  the  proc- 
ess has  been  checked,  for  the  resection  of  sequestra  or  the  trimming 
of  stumps. 


CHAPTER   XVI. 
DYSCHROMIAS. 

Cutaneous  Pigments. — The  human  skin  is  normally  pigmented 
throughout;  in  this  respect,  there  are  merely  differences  in  degree 
between  the  white  race  and  the  colored  races,  between  the  different 
regions  of  the  body  and  between  individuals  of  the  same  race. 

The  physiological  cutaneous  pigment  consists  of  extremely  small 
brown  or  black  grannies  of  an  organic  substance  named  melanin, 
which  contains  no  iron,  but  sulphur  in  variable  proportion.  The 
melanin  granules  are  situated  in  the  basal  layer  of  the  epidermis 
and,  furthermore,  when  the  pigmentation  is  very  marked,  in  certain 
cells  of  the  papillary  body;  the  color  of  the  hairs  and  of  the  choroid 
is  likewise  due  to  melanin. 

Under  pathological  conditions,  two  other  pigments  may  be  met 
with,  hemosiderin,  an  ochre  pigment  which  gives  the  reactions  for 
iron  and  is  formed  in  bloody  extravasates,  becoming  deposited 
exclusively  in  the  cutis;  and  the  paludean  pigment  which  is  charac- 
teristic of  malarial  melanodermia. 

Except  in  cases  which  will  receive  special  consideration,  the  dys- 
chromias are  due  to  variations  in  the  amount  of  melanin. 

Dyschromias. — The  name  "dyschromia"  is  applied  to  pathological 
changes  in  the  color  of  the  skin,  resulting  either  from  an  excess  or  a 
deficiency  of  pigment.  They  do  not  disappear  on  pressure  with  the 
finger,  resist  all  washing,  etc.,  and  ordinarily  persist  a  long  time, 
sometimes  throughout  life. 

As  a  rule,  there  is  an  excess  of  pigmentation.  These  hyper- 
chromias may  be  circumscribed,  representing  pigmentary  spots;  or 
diffuse,  representing  melanodermas. 

Hypochromic,  and  achromia  are  more  uncommon. 

When  the  latter  is  congenital,  it  is  known  as  albinism;  it  may  be 
generalized  or  localized.  Complete  albinism,  in  which  there  is  a  more 
or  less  total  absence  of  pigment  in  the  skin  and  its  appendages,  is  a 
grave  degeneration,  very  rare  in  the  human  race.  Albinos  have  a 
waxy  skin,  white  or  very  light  colored  hair  on  the  seal])  and  body 
and  ;i  red  or  bluish  iris. 

Partial  congenital  achromia  is  the  exact  oppositeof  a  pigmentary 
nevus;  it  is  often  familial,  circumscribed  in  a  nerve  territory  of  only 
one  side  of  the  body,  or  it  may  consist  of  a  few  white  spots,  known 
as  achromic  nevi. 


ARTIFICIAL  AND  SECONDARY  DYSCHROMIAS  321 

Acquired  hyperchromia  is  known  as  leukoderma  and  is  usually 
secondary  to  a  local  process.  It  is  frequently  associated  with 
hyperchromia  at  neighboring  points,  constituting  the  leukomelano- 
dermas  of  vitiligo  and  some  other  analogous  affections. 

The  causes  of  the  dyschromias  are  extremely  variable,  and  this 
pathogenic  mechanism  is  far  from  being  entirely  understood. 
Among  these  causes,  some  act  locally,  while  others  are  of  a  general 
kind,  such  as  intoxications,  infections,  changes  of  the  blood,  nervous 
disturbances. 

In  both  these  cases,  the  pigmentation  may  assume  the  form  of 
more  or  less  circumscribed  spots  or  it  may  become  diffused  over 
surfaces.  The  generalized  melanodermas  are  always  referable  to  a 
general  cause.  In  the  leukomelanodermas,  the  intervention  of  a 
nervous  disturbance  is  usually  admitted  as  essential. 

For  the  diagnosis  of  a  dyschromia  it  is  first  of  all  necessary  to 
ascertain :  if  it  is  secondary  to  another  process  (macules)  or  primary 
or  essential;  if  it  is  simple,  without  other  changes  of  the  integument, 
or  associated  with  a  dermatosis  of  different  character;  if  it  is  circum- 
scribed (pigmentary  spots)  or  diffuse  (melanoderma),  generalized  or 
regional. 

The  dyschromic  syndromes  to  be  discussed  in  the  following  have 
been  arranged  according  to  this  plan;  a  paragraph  has  been  added 
on  the  subject  of  vitiligo  and  other  leukomelanodermas. 

Finally,  although  these  conditions  are  not  due  to  pigmentary 
disturbances  but  to  foreign  bodies,  a  few  lines  are  devoted  to 
tattoo-marks  and  argyria. 


ARTIFICIAL  AND  SECONDARY  DYSCHROMIAS. 

Artificial  Pigmentations. — Any  cutaneous  irritation,  especially 
when  fairly  strong  and  prolonged,  may  become  the  origin  of  an  arti- 
ficial local  pigmentation.  Certain  individuals  are  evidently  predis- 
posed to  it  and  its  production  is  favored  by  stasis  of  the  blood,  as 
for  example  in  varicose  legs. 

In  some  cases,  the  pigmentation  is  the  direct  and  exclusive  result 
of  the  irritation;  in  others  it  follows  upon  a  hyperemia  or  even  a 
bullous  or  eczematous  process,  etc.,  belonging  in  the  last-named 
case  to  what  I  describe  as  macules. 

Mechanical  factors,  friction  by  the  clothing,  corsets,  shoes, 
bandages,  repeated  scratching  in  pruritus,  give  rise  to  hyperchromias 
of  an  often  characteristic  seat  and  configuration. 

Among  pigmentations  due  to  physical  factors,  it  suffices  to  call 
attention  to  the  following:  the  tanned  complexion  produced  by 
sunlight,  the  open  air,  electric  light,  the  a'-rays;  the  caloric  pigmen- 
21 


322  DYSCHROMIAS 

tatioD  of  the  face,  forearms  and  trunk  in  blacksmiths,  glass-blowers, 
bakers,  etc.;  of  the  thighs,  in  out-of-doors  hucksters  who  have  the 
habit  of  sitting  on  their  foot-warmers  and  of  any  region  of  the  body 
in  persons  who  have  abused  hot  compresses  <>r  very  hot  lotions  for 
the  nlicf  of  pain,  pruritus,  etc.;  this  is  often  arranged  after  the 
fashion  of  a  wide-meshed  network.  [The  dermatitis  calorica  of 
furnace  men  and  others  exposed  to  great  heat  is  commonly  followed 
by  this  reticular  pigmentation.]  Many  chemical  agents  may  cause 
very  persistent  pigmentations,  even  without  a  caustic  action;  and 
it  is  well  for  the  physician  to  he  forewarned,  so  as  to  avoid  reproach 
under  some  condition-.  This  remark  applies  to  nearly  all  rube- 
facients and  counter-irritants,  notably  mustard  plasters,  methyl 
chloride,  chloroform,  tincture  of  iodin,  etc.  Applications  of  chrysa- 
robiii  usually  give  rise  to  a  bronzed  erythema,  followed  by  an 
extensive  but  temporary  brownish  pigmentation  from  which  the 
healed  patches  of  psoriasis  stand  out  in  white. 

The  treatment  of  the  artificial  pigmentations  consists  in  the 
removal  of  the  cause  of  the  hyperchromia  and  in  the  employ- 
ment of  topical  agents  which  will  be  discussed  in  connection  with 
chloasma. 

Macules.-  I  June  for  a  long  time  been  accustomed  to  reserve 
1 1 1 i s  name,  which  is  popularly  used  interchangeably  with  the  word 
spots,  for  the  dyschromic  but  not  cicatricial  residues  of  a  large 
number  of  cutaneous  affections. 

They  follow  upon  excoriations,  upon  erythematous,  vesicular, 
eczematous,  bullous  eruptions,  such  as  burns,  blisters  from  vesicants; 
purulent  bulhe  of  impetigo;  superficial  folliculitides;  the  multiple 
lesions  of  scabies;  papules  of  all  kinds,  etc. 

They  consist  of  a  local,  often  distinctly  circumscribed,  pigmenta- 
tion or  sometimes  of  a  central  hypochromia  surrounded  by  a  pig- 
mentary halo.  They  are  often  scaly  at  the  onset  and  then  of  a 
perfectly  normal  surface. 

In  the  absence  of  sufficient  observation  or  information,  maculae 
may  lead  to  numerous  errors  of  diagnosis.  It  is  necessary  to  guard 
against  the  confusion  of  macula?,  whose  epidermis  has  its  normal 
structure  and  which  are  always  temporary,  with  deaf  rices-  which 
are  always  permanent. 

The  seat,  extent  and  configuration  of  the  macules  often  possess 
important  indicative  value  in  regard  to  the  causative  dermatosis. 
The  hyperchromic  tendency  of  syphilitic  papules  of  all  kinds,  in 
certain  individuals,  has  long  been  emphasized.  These  syphilides 
nigricantes,  to  use  A.  Founder's  term,  are  sometimes  a  source  of 
great  distress  for  the  patient. 

A  special  group  of  pigmentary  macules  of  hemorrhagic  origin,  in 
which  the  pigment    is   hemosiderin,  is   represented    by  the  brown 


PIGMENTARY  SPOTS  323 

spots  following  on  traumatic  or  purpuric  ecchymoses,  hemorrhagic 
urticaria,  varicose  eczema,  etc. 

Under  the  name  of  pigmentary  dermatosis  of  the  legs  (or  dermite 
jawne  d'ocre)  have  been  separately  described  large  more  or  less 
distinctly  outlined  spots  of  a  uniform  brown  or  mottled  color,  which 
are  frequently  observed  on  the  legs  of  arteriosclerotic,  varicose  or 
diabetic  individuals,  or  in  Bright's  disease,  etc.,  and  which  persist 
indefinitely.  They  result  from  minute  interstitial  frequently  repeated 
hemorrhages. 

ASSOCIATED  DYSCHROMIAS  OR  DYSCHROMIC  DERMATOSES. 

Several  dermatoses  give  rise  to  a  black  or  dark  coloration  of  the 
integument  which  is  not  dyschromic,  in  so  far  as  it  results  exclusively 
from  an  abnormal  hue  of  the  horny  layer.  In  such  cases,  the  colored 
layer  can  be  finally  detached  by  energetic  scratching.  This  occurs 
in  many  hyperkeratoses  and  keratodermas,  in  ichthyosis  niger,  in 
psorospermosis  follicularis,  in  certain  seborrheas  nigricantes,  in 
pityriasis  versicolor,  in  the  carates  [pinta],  etc.,  and  to  a  less  degree, 
in  kerosis. 

Some  dermatoses  are  actually  pigmentary  anomalies  or  may 
lead  to  such.  Spots  from  antipyrin  and  from  leprosy  are,  as  a  rule, 
ery  themato-pigmented . 

Various  eruptions  will  be  mentioned  further  on,  which  may  be 
accompanied  by  a  sort  of  pigmentary  ataxia,  such  as  lichen  planus, 
various  prurigos,  etc. 

Pigmentations  also  form  an  essential  part  of  the  pathological 
disturbances  of  acanthosis  nigricans,  xeroderma  pigmentosum  and 
several  analogous  cutaneous  dystrophies;  of  v.  Recklinghausen's 
disease  and  urticaria  pigmentosa. 

The  reader  is  finally  reminded  of  the  pigmentary  tumors,  malig- 
nant, such  as  the  nevo-carcinomata  or  pigmented  sarcomas;  or 
benign,  such  as  pigmented  nevi. 

In  this  entire  group  of  associated  dyschromias,  it  is  the  underlying 
dermatosis,  characterized  by  its  peculiar  lesions  which  establishes 
the  diagnosis,  governs  the  prognosis,  determines  the  treatment  and 
explains  the  pigmentation. 

PIGMENTARY  SPOTS. 

Ephelides.  —  Ephelides,  or  freckles,  confused  by  some  derma- 
tologists with  lentigo,  are  small  lenticular,  rounded  or  oval,  more 
rarely  irregular  spots,  of  a  light  yellow,  cafe-au-lait  or  brownish 
color,  perfectly  flat,  smooth  and  not  scaly,  generally  isolated  and 
numerous,  or  very  profuse  and  agminated  if  not  confluent,  sym- 
metrically arranged,  having  their  seat  of  predilection  on  the  face, 


324  DYSCHROMIAS 

the  nose,  the  prominences  of  the  cheek  bones,  the  forehead,  the 
hands  and  forearms.  More  rarely,  they  are  scattered  over  the 
shoulders,  the  arms,  the  legs,  the  buttocks  and  the  genitals. 

Ephelides  are  not  congenital,  but  appear  during  childhood  and 
youth,  especially  in  blond  or  red-haired,  anemic  or  lymphatic  indi- 
viduals and  in  persons  enjoying  excellent  health. 

Sunlight  undoubtedly  plays  a  considerable  part  in  the  mechanism 
of  their  onset,  as  suggested  by  their  name;  also,  they  are  much  more 
apparent  during  the  spring  and  summer  than  in  winter.  But  on 
the  other  hand,  they  are  plainly  hereditary  or  atavistic  in  certain 
families;  they  develop  also  in  covered  regions  of  the  body  and  are 
in  every  way  comparable  to  nevi. 

The  histology  of  ephelides  shows  merely  an  abnormal  quantity  of 
pigment  in  the  basal  epidermic  cells,  with  presence  of  pigmentary 
cells  in  the  papillary  body. 

Chloasma. — Chloasma  uterinum  consists  of  spreading  spots, 
irregular  in  shape  and  outline,  sometimes  confluent  in  patches,  of  a 
yellow,  brownish,  or  still  darker  color,  situated  almost  invariably 
symmetrically  on  the  forehead,  the  temples,  the  lateral  portions  of 
the  cheeks  and  more  rarely  on  the  eyelids,  the  chin,  or  at  other 
points  of  the  body.  The  well-marked  outline  of  chloasma  dis- 
tinguishes it  from  the  caloric  and  solar  pigmentations. 

Chloasma  ordinarily  develops  in  pregnant  women  and  persists 
until  the  reestablishment  of  menstruation  and  often  throughout 
life.  At  the  same  time,  or  even  in  its  absence,  there  appears  a  pig- 
mentation of  the  linea  alba,  the  areola  of  the  nipples  and  the  vulva, 
especially  in  brunettes.  Various  pathological  conditions,  metritis, 
salpingitis,  dysmenorrhea,  etc.,  may  produce  identical  pigmenta- 
tions. Cases  of  chloasma  without  a  demonstrable  cause  are  also 
met  with. 

It  seems  probable  to  me  that  an  irritation  of  the  abdominal 
sympathetic  nervous  apparatus  enters  into  its  pathogenesis,  as  in 
the  case  of  Addison's  disease  [and  probably  in  acanthosis  nigricans.] 

The  treatment  of  chloasma,  like  that  of  the  ephelides  and  arti- 
ficial pigmentations,  yields  no  satisfactory  results.  Prophylactic 
measures  would  be  the  most  advisable,  with  avoidance  in  predis- 
posed persons,  of  cutaneous  irritation  or  exposure  to  light;  suitable 
treatment  of  uterine  and  abdominal  affections  or  anemia  and  the 
lymphatic  constitution  when  present.  The  administration  of 
arsenic,  which  produces  hyperchromia,  is  contra-indicated. 

Locally,  so-called  decolorizing  washes  may  be  prescribed,  appli- 
cations of  mercurial  plasters  during  the  night,  or  salicylated  calomel 
partes,  or  some  peroxide  cream.  Exfoliation  by  means  of  exfoliating 
pastes  is  often  successful  in  decolorizing  the  hyperchromic  surfaces, 
but  the  cure  is  as  a  rule  merely  temporary. 


DIFFUSE  DYSCHROMIAS  AND  MELANODERMAS         325 

Disseminated  Pigmentary  Spots. — As  has  just  been  shown,  the 
ephelides  and  chloasma  are  regional  affections.  In  the  presence  of 
disseminated  yellow  or  brownish  pigmentary  spots,  or  a  single  spot, 
it  is  necessary  to  think  in  the  first  place  of  the  artificial,  macular 
and  secondary  pigmentations  which  have  been  discussed  in  the 
preceding  paragraphs;  next,  of  the  pigmentary  nevi  and  of  v.  Reck- 
linghausen's disease,  which  includes  some  abortive  forms,  exclu- 
sively pigmentary;  finally,  one  must  keep  in  mind  the  possibility 
of  circumscribed  pigmentations  in  several  melanodermas  due  to 
general  causes. 

The  blue  or  shaded  spots  produced  by  the  bite  of  phthirius 
inguinalis  or  the  crab-louse,  are  characterized  by  their  peculiar 
slate-blue  coloring.  They  are  of  irregular  form,  of  lenticular  or 
nummular  dimensions;  the  epidermis  is  in  no  way  changed;  they 
cause  no  itching  and  are  of  ephemeral  duration  [up  to  a  week  or 
more].  They  are  situated  in  variable  numbers  on  the  abdomen, 
the  thighs,  the  back,  and  sometimes  on  the  chest.  The  experiments 
of  Duguet  have  shown  them  to  be  due  to  the  local  action  of  the 
venom  of  the  parasite. 

DIFFUSE  DYCHROMIAS  AND  MELANODERMAS. 

Diffuse  pigmentations,  whether  generalized  or,  what  is  more 
common,  regional  or  with  regional  predominance,  are  referable  to : 
chronic  infections,  such  as  tuberculosis,  syphilis,  leprosy  and  pellagra ; 
or  to  intoxications,  such  as  arsenicism  and  phthiriasis;  or  to  a  variety 
of  blood  diseases;  or  to  diseases  of  the  nervous  system.  Occasionally, 
leukoderma  is  intermingled  with  hyperchromia. 

Addisonian  and  Tuberculous  Melanodermas. — In  Addison's  dis- 
ease, the  bronzed  coloration  of  the  integument  is  often  delayed; 
but.  it  may  also  precede  by  several  years  the  other  symptoms,  such 
as  asthenia,  digestive  disturbances  and  lumbar  pains.  The  pig- 
mentation, which  is  diffuse,  of  a  red-brown  or  gray-brown  color, 
first  involves  and  stains  the  genital  organs,  the  areolae  of  the 
breasts,  the  articular  folds  and  the  uncovered  portions,  face  and 
hands,  and  long-standing  or  recent  scars.  Jacquet  has  shown  that  a 
local  irritation  may  "externalize"  a  latent  tendency  to  pigmenta- 
tion. On  the  hyperchromic  surfaces,  normal  areas  simulating 
leukodermic  spots  are  sometimes  seen. 

Very  commonly  the  pigmentation  involves  also  the  buccal  mucosa, 
where  tan  or  brownish  spots,  distinctly  outlined  or  with  diffuse 
margins,  are  noted  on  the  cheeks,  the  lips,  the  tongue,  the  gums 
and  the  palate.  [Pigmentation  of  the  mucosa  sometimes  precedes 
that  of  the  cutaneous  surface.]  The  cutaneous  and  mucous  lesions 
consist  of  an  excess  of  melanin  in  the  epidermis  and  cutis. 


326  DYSCHROMIAS 

The  melanoderma  of  Addison's  disease  is  now  known  to  be 
referable,  not  so  inneh  to  a  change  of  the  suprarenal  bodies  them- 
selves as  to  a  lesion  or  irritation  of  the  pericapsular  sympathetic 
nerve  apparatus  which  apparently  presides  over  the  regulation  of 
the  pigment.  It  has  occurred  to  me  that  the  pigmentations  of 
acanthosis  nigricans,  of  chloasma  and  perhaps  that  of  pigmentary 
syphilides,  may  have  an  analogous  pathogenesis. 

The  melanoderma  of  tuberculous  patients  has  long  been  known, 
especially  in  cases  of  tuberculous  peritonitis  or  enteritis.  It  con- 
sists of  a  dusky  or  brownish  coloring  of  the  genitals,  the  abdomen 
and  sometimes  the  neck.  It  evidently  results  from  the  same  condi- 
tions as  genuine  Addison's  disease,  from  which  it  differs  as  a  rule 
only  by  its  more  limited  diffusion  especially  on  uncovered  parts. 

Pigmentary  Syphilides. — Aside  from  the  posteruptive  pigmentary 
macules  referred  to  before  and  the  tertiary  leukomelanodermas  to 
be  discussed  further  on,  syphilis  very  frequently  produces  a  truly 
specific  areolar  pigmentation  of  the  neck,  which  ranks  among  its 
most  significant  symptoms. 

This  areolar  pigmentary  syphilide  is  more  common  in  women 
than  in  men.  It  appears  as  early  as  the  second  or  third  month,  or 
in  the  course  of  the  first  year,  rarely  after  two  years  and  has  a  very 
indefinite  duration  which  it  is  very  difficult  to  determine  [five  to 
fourteen  months,  according  to  Jadassohn].  It  consists  of  a  grayish 
or  brownish  more  or  less  dark  hyperchromia,  with  diffuse  borders, 
interspersed  with  islands  of  distinctly  outlined  white  spots  varying 
in  size  from  a  lentil  to  a  franc,  so  that  the  whole  forms  a  network 
with  large  strands,  usually  better  marked  on  the  lateral  portions 
of  the  neck  (Fig.  109).  This  "necklace  of  Venus"  may  send  radiat- 
ing processes  on  the  chest,  often  in  front  of  the  axilla1,  on  the  flanks, 
or  still  farther.  In  some  cases,  pigmentary  macules  are  found  in  the 
center  of  a  few  of  the  white  areola3. 

The  pathogenesis  of  areolar  syphilide  is  still  a  matter  of  contro- 
versy. By  some,  the  pigmentation  is  interpreted  as  the  primary 
and  exclusive  feature,  the  apparent  decoloration  of  the  meshes  being 
referable  to  a  contrast-effect;  others  assume  true  leukodermic  patches, 
following  upon  a  sometimes  not  very  evident  eruption,  which  become 
secondarily  surrounded  by  hyperpigmented  areas. 

It  is  more  than  probable  that  both  these  interpretations  are 
correct  in  different  cases  and  that  there  are  really  two  modes  of 
formation  of  the  pigmented  network. 

This  dyschromia  is  almost  pathognomonic.  However,  a  few  old 
observations  are  on  record  of  areolar  pigmentations  of  the  same  type 
referable  to  tuberculosis  and  chlorosis;  these  date  back,  it  must  be 
noted,  to  a  period  prior  to  the  discovery  of  the  serodiagnosis  of 
syphilis. 


DIFFUSE  DYSCHROMIAS  AND   MELANODERMAS         327 

Inversely,  pigmentations  of  another  type,  analogous  to  chloasma, 
for  example,  have  been  noted  in  secondary  syphilis. 

The  syphilitic  hyperchromias  are  practically  not  amenable  to 
specific  treatment. 


Fig.  II 


-Areolar  pigmentary  syphilide  of  the  neck.     (After  a  east  in  the  Museum 
of  the  St.  Louis  Hospital.) 


Dyschromias  of  Leprosy. — The  initial  erythemato-pigmented 
spots,  leprous  pemphigus,  tubercles,  infiltrations  and  ulcers  often 
leave  behind  them  hyperchromic  or  plainly  achromic  spots,  or 
leukomelanodermas  resulting  from  a  combination  of  these  two 
opposite  disturbances. 

For  instance,  white  spots  with  a  pigmented  border  may  be 
observed — annular,  band-like,  or  diffuse,  or  dark  surfaces  dotted 
with  colorless  spots,  etc. 

All  these  various  manifestations,  which  were  formerly  designated 
under  the  names  of  melas,  leuke,  morphea  alba  et  nigra,  vitiligo 
gravior,  are  usually  characterized  by  anesthesia. 

The  distribution  of  the  pigment  is  variable.  Hansen's  bacilli  are 
almost  regularly  demonstrable  in  sections  of  the  skin,  although  in 
very  small  number. 

Dyschromias  of  Nervous  Diseases. — In  the  organic  diseases  of 
the  nervous  system,  the  disturbances  of  pigmentation  are  usually 
not  pronounced. 

In  hemiplegia,  cerebral  tumors,  infantile  paralysis,  progressive 
muscular  atrophy,  syringomyelia,  tabes,  the  traumatic  or  toxic 
neuritides,  etc.,  slight  modifications  in  the  coloring  of  the  skin  have 
been  reported,  associated  with  other  trophic  disturbances,  hyper- 
trichosis or  alopecia,  hyperidrosis,  etc.  The  same  observations  have 
been  made  in  mental  diseases  of  the  depressive  or  melancholic  type. 


328  DYSCHROMIAS 

On  the  contrary,  the  dyschromias  are  abundantly  represented  on 
the  borderland  of  nervous  pathology,  in  diseases  placed  here  by 
their  symptoms.  In  Raynaud's  disease,  in  myxedema,  in  exoph- 
thalmic  goitre,  they  are  of  frequent  occurrence;  vitiligo  is  rather 
common  in  Graves'  disease. 

In  scleroderma  under  its  different  aspects,  which  can  hardly  be 
considered  simply  a  nervous  disease  and  in  facial  hemiatrophy, 
which  is  related  to  it  in  some  respects,  hyperchromia  is  a  nearly 
constant  symptom.  A  more  or  less  deep,  diffuse,  areolar  or  spotted, 
primary  or  delayed  pigmentation  is  noted,  occupying  the  sclerotic 
areas,  or  the  neighboring  regions,  or  sometimes  a  large  extent  of 
the  integument.  Depigmentation  of  the  sclerotic  patches  or  regions 
i-  also  not  uncommon. 

Dyschromias  in  Diseases  of  the  Blood  and  in  Cachexias. — It  is 
enough  to  mention  the  hypochromia  which  may  be  seen  in  chlorosis, 
the  chloro-anemias,  pernicious  anemia,  the  leukemias  and  in  cancer- 
ous cachexia. 

Inversely,  it  is  not  exceptional  to  observe  various  diffuse  or 
regional  melanodermas  in  these  diseases  more  particularly  in  Banti's 
disease  and  in  the  psendo-leukemias. 

The  melanoderma  of  bronzed  diabetes,  with  or  without  pigment- 
ary hypertrophic  cirrhosis,  is  generalized,  almost  invariably  spares 
the  mucous  membranes  and  consists  of  an  infiltration  into  the  cutis 
as  well  as  other  tissues,  of  an  ochre-colored  pigment  known  as  rubigin. 

In  malarial  cachexia,  the  coloration  is  ashy,  a  dirty  gray,  or  yellow 
gray,  diffusely  and  uniformly  distributed.  The  malarial  pigment, 
which  is  specific,  is  derived  from  the  malaria-parasites,  is  carried  to 
the  skin  by  the  blood  (melanemia),  and  is  here  deposited,  associated 
with  an  ochre  pigment  of  hemic  origin  [hemosiderin]. 

Arsenical  Dyschromias. — Arsenical  melanoderma  may  develop 
independently  of  the  age  and  sex  of  the  patient  or  the  nature  of  the 
arsenical  remedy  and  its  mode  of  introduction.  Very  minute  doses 
are  sometimes  sufficient  for  its  production,  although  as  a  rule,  a 
prolonged  absorption,  medicinal,  occupational,  or  accidental,  is 
responsible. 

The  pigmentation  may  assume  two  forms  which  are  sometimes 
combined;  that  of  diffuse  hyperchromia  predominating  in  normally 
colored  areas,  cicatrices,  or  cutaneous  regions  which  are  subject 
to  pressure,  or  that  of  pigmentary  spots,  which  enlarge  and  become 
confluent.  In  patients  who  have  been  improperly  treated  with 
arsenic  for  psoriasis  or  lichen,  a  very  deep  generalized  melanoderma 
is  sometimes  observed. 

The  coloration  is  iron-gray,  bronzed,  or  even  black.  The 
uncovered  regions  remain  relatively  free,  as  well  as  the  mucous 
membranes,  with  very  rare  exceptions. 


VITILIGO  329 

Pediculous  or  Phthiriasic  Melanoderma. — In  paupers,  tramps, 
scavengers  and  rag-pickers  living  in  filth  and  misery,  exposed  to  all 
sorts  of  vermin  and  whose  clothing  sometimes  harbors  incredible 
numbers  of  pediculi  corporis,  this  condition  is  known  to  occur, 
so  that  the  name  of  Vagabond's  disease  is  usually  entirely  justified. 

The  pigmentation,  of  a  dirty  brown  mottled  with  excoriations, 
crusts  and  cicatrices,  predominates  on  the  back,  the  nape  of  the  neck, 
the  shoulders,  the  waistline,  and  the  thighs;  but  it  may  spread  all 
over  the  integument,  including  the  face  and  the  extremities. 

Thibierge  has  shown,  and  I  was  repeatedly  enabled  to  verify  the 
fact,  that  the  pigmentation  is  observed  even  on  the  buccal  mucosa, 
in  the  form  of  spots  resembling  those  of  Addison's  disease. 

The  hyperchromia  has  been  attributed  to  scratching,  to  bloody 
extravasations  and  to  the  local  action  of  the  venom  of  the  lice. 
Its  generalization  and  its  possible  localization  in  the  mouth,  show 
that  this  poison  has  a  systemic  action.  The  asthenia,  the  often  very 
cachectic  appearance  of  the  patients,  and  the  digestive  disturbances 
from  which  they  suffer,  are  additional  proofs  of  this  contention  and 
help  to  render  the  differential  diagnosis  from  Addison's  disease  very 
difficult  in  some  cases. 

VITILIGO. 

Vitiligo  is  a  non-congenital  dyschromia  characterized  by  the 
appearance  of  achromic  or  strongly  hypochromic  white  spots,  which 
are  sharply  limited  and  surrounded  by  a  more  or  less  extensive  zone 
of  hyperpigmentation. 

Aside  from  the  change  in  color,  the  skin  presents  no  alteration 
of  its  surface,  consistence  or  function. 

The  white  spots  of  vitiligo  have  a  milky  or  ivory  hue,  a  dull 
sheen,  a  generally  round,  oval,  or  polylobular  form,  distinct  faintly 
sinuous  outlines.  Sometimes  they  are  in  small  numbers,  but  in 
other  cases  they  may  be  so  profuse  and  numerous  as  to  cover  a 
large  portion  or  nearly  the  whole  of  the  integument  (Fig.  110). 

The  hyperchromia  of  the  intermediate  regions,  which  have  a 
brown  or  grayish  hue,  is  often  particularly  marked  at  the  very 
border  of  the  white  spots;  this  arrangement  conveys  the  impression 
of  the  pigment  having  been  pushed  out  from  the  achromic  surfaces. 
At  the  periphery  of  the  hyperpigmented  zones,  the  transition  into 
the  normal  color  is  gradual  and  imperceptible,  rarely  marked  by  a 
distinct  boundary. 

The  down  and  hairs  of  the  white  spots  are  either  entirely  colorless 
or  of  normal  color. 

The  dyschromia  is  associated  with  no  sensory  disturbance,  neither 
pain,  nor  itching,  nor  noteworthy  anesthesia  being  demonstrable. 

Jadassohn  points  out  that  the  white  spots  are  more  susceptible 


DYSCHROMIAS 


to  solar  erythema,  while  they  arc  on  the  contrary  more  resistant 
to  various  cutaneous  irritations  and  relatively  immune  to  certain 
eruptions. 

The  topography  of  vitiligo  is  extremely  variable,  not  infrequently 
its  distribution  is  more  or  less  symmetrical.  It  may  occupy  any 
region,  although  it  show-  a  certain  predilection  for  the  back  of  the 
hands,  the  wrists  and  the  forearms,  the  face  and  neck  and  for  the 
genital  organs  and  the  neighboring  areas.  The  mucosas  are  always 
intact. 

The  course  of  the  affection  i-  governed  by  no  rule;  it  may  appear 
suddenly  or  more  often  insidiously;  it-  extension  i-  gradual  and 
almost   imperceptible  or  sometime-  occurs  in  successive  attacks. 


f    «  Ji 

Hi*-                 r 

110.— Vitiligo. 


The  dyschromia  may  remain  almost  stationary,  with  seasonal 
variations  of  its  shade-;  more  commonly,  the  white  spot-  spread 
and  become  confluent  in  patches;  they  may  even  become  generalized; 
Inn  at  the  same  time  the  degree  of  the  hyperchromia  diminishes. 
A  complete  cure  is  very  rare. 

The  etiology  of  vitiligo  is  unknown.  Adolescence,  youth  and  the 
female  sex  seem  to  be  relatively  predisposing.  It  has  been  known 
to  occur  in  persons  who  had  been  exposed  to  a  nervous  or  emo- 
tional shock.  Repeated  traumatisms  certainly  play  a  part,  for 
vitiligo  is  not  rare  at  point-  exposed  to  friction  a-,  for  instance, 
from  a  hernial  truss. 

Moreover,   it    becomes  associated   too  frequently  for  a   merely 


SECONDARY  LEUKODERMAS  AND  LEUKOMELANODERMAS   331 

accidental  combination,  with  alopecia,  circumscribed  prurigos, 
lichen  planus,  scleroderma  and  with  a  variety  of  nervous  diseases, 
notably  tabes  dorsalis  and  exophthalmic  goiter. 

Like  several  writers,  I  have  been  struck  with  the  relative  fre- 
quency of  syphilis  in  patients  with  vitiligo;  however,  there  is  at 
present  no  reason  for  admitting  the  existence  of  a  syphilitic  vitiligo, 
nor  especially  that  all  vitiligo  depend  upon  this  infection. 

The  pathological  anatomy  shows  the  almost  complete  disappear- 
ance of  the  pigment  in  the  leukodermic  spots  and  its  abundance 
on  the  contrary  in  the  epidermis  and  derma  of  the  hyperchromic 
regions;  but  it  affords  no  information  as  to  the  pathogenesis  of 
these  lesions. 

The  diagnosis  is  very  easy  in  the  vast  majority  of  the  cases.  An 
even  cursory  examination  suffices  to  guard  against  confusion  with 
pityriasis  versicolor  and  with  the  various  pigmentations,  circum- 
scribed or  diffuse,  but  without  achromic  spots,  which  have  been 
mentioned  in  the  course  of  this  chapter.  The  light  areolas  of  the 
pigmentary  syphilide  of  the  neck,  which  is  moreover  characterized 
by  its  seat,  as  well  as  those  which  may  eventually  be  encountered 
in  various  melanodermas,  are  usually  preserved  normal  skin  areas 
and  not  leukodermas. 

The  only  real  difficulties  which  may  present  themselves  are  the 
following:  In  the  course  of  leprosy,  pigmented  surfaces  and 
achromic  spots  have  been  demonstrated  and  as  a  whole  have  been 
designated  as  vitiligo  gravior;  very  evident  sensory  disturbances  are 
present  in  these  cases. 

In  certain  families  of  temperate  zones  and  more  frequently  in 
the  colored  races,  congenital  leukomelanodermas  or  cases  of  partial 
albinism  have  been  noted ;  the  dyschromia  in  these  cases  is  absolutely 
stationary  and  sometimes  symmetrical.  So-called  piebald  negroes 
are  probably  in  part  referable  to  this  congenital  anomaly  and  in 
part  to  vitiligo  or  to  leprosy. 

The  treatment  of  vitiligo  usually  is  not  very  effective.  In  those 
cases  where  syphilis  seems  to  be  involved,  or  in  the  coexistence 
of  tabes,  mercurial  treatment  should  be  administered  and  I  have 
obtained  a  remarkable  success  in  one  instance.  It  is  to  be 
feared  that  arsenic  may  aggravate  the  hyperchromia.  As  a  rule, 
nothing  can  be  done  but  to  regulate  the  patient's  general  hygiene, 
to  prescribe  sedative  or  tonic  hydrotherapy  and  electric  treatments. 
Various  opotherapies  might  be  indicated  in  this  affection.  The 
overpigmented  zones  may  be  treated  with  the  customary  decolorizing 
agents. 

Secondary  Leukodermas  and  Leukomelanodermas. — These  are 
distinguished  from  vitiligo  by  this  essential  characteristic  that  the 
dyschromia  here  is  not  simple,  but  accompanies  an  eruptive  mani- 


332  DYSCHROMIAS 

festation,  or  a  change  in  the  thickness,  consistence  and  structure 
of  the  skin. 

There  is  a  coexisting  eruption,  with  disturbances  in  pigmentation, 
in  lichen  planus,  lichen  hypertrophicus,  circumscribed  prurigo,  etc. 

There  is  sclerosis  or  atrophy  of  the  skin  in  the  following  cases: 
the  leukodermic  spots  of  circumscribed  scleroderma,  also  known  as 
morphcea  nostras,  which  are  bordered  by  a  lilac  ring;  the  morphcea  of 
lepras)/  which  is  anesthetic  and  contains  Hansen's  bacillus;  the 
cutaneous  atrophies  in  patches,  often  preceded  by  an  erythematous 
stage;  lichen  planus-  atrophicus  which  has  been  papular;  sclerotic 
radiodermatitis,  which  is  interspersed  with  telangiectases. 

Cicatrices,  no  matter  of  what  origin,  as  well  as  linear  atrophies 
are  sometimes  pigmented  or  leukodermic  and  in  the  latter  case 
often  surrounded  by  a  zone  of  hyperchromia.  This  is  of  especially 
common  occurrence  in  the  cicatrices  of  tertiary  syphilis.  Under 
the  name  of  syphilitic  leukomelanodermas,  extreme  cases  have  been 
described,  by  A.  Fournier,  Gemy,  etc.,  in  which  the  skin  finally 
becomes  mottled  with  black  spots,  or  sometimes  with  rounded  or 
polycyclic  white  spots  in  the  midst  of  pigmented  surfaces,  so  as  to 
simulate  vitiligo  from  a  distance. 


TATTOO  MARKS  AND  ARGYRIA. 

Tattoo  marks  are  spots  on  designs  produced  by  the  deliberate 
introduction  of  colored  and  insoluble  particles  into  the  cutis  where 
they  persist  indefinitely. 

These  more  or  less  artistic  tattoo  marks  and  inscriptions  are 
usually  made  with  lamp  black  or  India  ink  when  they  are  blue,  or 
with  vermilion  when  they  are  red;  the  colored  powder  is  made  to 
penetrate  by  means  of  closely  bunched  very  fine  needles.  Tattoo 
marks  are  commonly  seen  in  sailors,  colonial  soldiers,  prostitutes 
and  their  cadets;  but  also  occasionally  in  the  educated  classes,  as 
the  effect  of  a  peculiar  aberration. 

Powder  spots,  resulting  from  a  gunshot  fired  at  close  range  and 
from  the  penetration  of  bits  of  charcoal,  have  a  characteristic 
arrangement. 

In  certain  occupations,  among  grinders,  filers,  stone-breakers, 
miners,  etc.,  particles  of  steel,  Mint,  or  coal,  may  penetrate  into  the 
cutis  and  cause  a  sort  of  occupational  tattooing. 

Electrolysis,  or  hypodermic  injections  applied  with  steel  needles, 
may  likewise  leave  prints  of  siderosis. 

Argyria  is  a  slaty  coloration,  with  bluish  reflexes,  which  develops 
in  persons  exposed  to  the  prolonged  absorption  of  silver  nitrate 
pills  or  other  silver  salts.     It  is  generalized,  but  much  more  pro- 


TATTOO  MARKS  AND  ARGYRIA  333 

nounced  on  the  face,  the  hands  and  the  articular  folds  and  may  also 
affect  the  mucous  membranes. 

The  silver  granules,  conveyed  by  the  bloodstream,  impregnate 
especially  the  elastic  fiber  and  the  capillaries,  sparing  the  cellular 
elements. 

Spots  of  local  argyria  may  be  encountered  on  the  buccal,  con- 
junctival and  vulvar  mucosa?,  following  upon  energetic  cauteriza- 
tions with  lunar  caustic.  [Very  distressing  cases  of  local  and  even 
quite  extensive  argyria  have  followed  the  use  of  the  organic  silver 
compounds  in  the  treatment  of  dachryocystitis.] 

Treatment. — In  order  to  remove  tattoo-marks,  which  is  difficult, 
various  caustic  agents  may  be  used.  Variot  recommends  retattooing 
with  a  concentrated  solution  of  tannin  and  then  passing  a  silver 
nitrate  pencil  over  the  surface.  A  dry  slough  is  formed,  which 
brings  the  tattoo  mark  away  with  it,  provided  the  slough  is  deep 
enough.  I  have  advantageously  employed  crossed  linear  scarifica- 
tion followed  by  cauterization  with  pure  carbolic  acid.  Applica- 
tions of  carbonic  acid  snow  have  also  been  recommended. 


CHAPTER    XVII. 

CUTANEOUS  ATROPHIES,  SCLEROSES  AND 
DYSTROPHIES. 

Cutaneous  atrophy  is  a  nutritional  disturbance  of  the  skin  in  which 
there  is  a  diminution  in  the  number  or  volume  of  its  constituents, 
the  clastic  tissue  in  particular;  clinically,  it  manifests  itself  as  a 
diminution  of  the  actual  thickness  or  consistence  of  the  integument. 
The  atrophic  skin  is  therefore  more  supple,  more  easily  folded  and 
often  thinner  than  the  normal  skin,  its  color  is  usually  altered, 
either  pinkish  or  of  a  pearly  white.  Sometimes,  as  in  certain  linear 
atrophies,  for  instance,  the  skin  seems  to  he  thickened  on  inspection, 
while  remaining  soft,  depressible  and  easily  folded;  this  depends 
upon  its  relaxation  and  infiltration  by  plasma,  or  upon  the  atrophied 
portion  being  pushed  out,  as  it  were,  by  the  tension  of  the  normal 
and  more  resistant  integument  of  the  vicinity  (see  Fig.  111). 

Cutaneous  .sclerosis  is  a  condensation  of  the  skin-components, 
which  may  or  may  not  be  increased  in  size  and  number,  but  are 
always  more  heaped  tip  and  move  less  readily  over  each  other. 
The  sclerotic  skin  may  therefore  be  thickened  or  normal  or  even 
thinned;  in  the  latter  case  it  seems  to  be  atrophic;  but  it  is  always 
more  firm,  less  depressible,  generally  difficult  to  fold  and  often  it  is 
adherent  to  the  subjacent  tissues. 

Although  atrophoderma  and  dermatosclerosis  constitute  different 
and  in  some  respects  opposite  conditions,  they  are  sometimes 
difficult  to  distinguish  clinically;  they  are  often  combined  or  asso- 
ciated or  follow  one  another,  so  that  it  is  advisable  to  study  the 
syndromes  in  which  they  are  met  with  in  the  same  chapter. 

Finally,  there  exist  alterations  of  the  skin  which  can  hardly  be 
designated  otherwise  than  as  cutaneous  dystrophics.  The  integu- 
ment here  is  sometimes  thinned,  in  other  cases  swollen,  while  its 
consistence  is  usually  diminished.  They  form  a  natural  group 
which  logically  takes  its  place  by  the  side  of  the  preceding. 

The  pathogenesis  of  these  atrophies,  scleroses,  and  dystrophies  is 
sometimes  evident,  often  on  the  contrary  very  obscure  and  cer- 
tainly not  uniform.  Sometimes  they  arc  congenital  and  represent 
actual  malformations  (example:  atrophic  nevi,  xeroderma  pigmen- 
tosum); in  other  cases  they  behave  like  degenerations  due  to  old 
age,  repeated  exogenic  or  endogenic  irritations;  again,  they  are 
secondary  to  a  more  or  less  definite    inflammatory  or  neoplastic 


SCLEROTIC  AND  ATROPHIC  DERMATOSES  335 

process,  of  which  they  constitute  a  necessary  or  possible  residue; 
or  finally  they  seem  to  be  primary  or  idiopathic,  supervening  with- 
out apparent  cause  and  without  being  preceded  by  demonstrable 
lesions,  so  that  their  etiology  and  their  mechanism  altogether 
escape  us. 

Sometimes  a  relation  may  be  observed  between  the  dermatosis 
and  some  disturbances  of  the  general  health,  but  this  is  entirely 
absent  in  other  cases. 

Sclerotic  and  Atrophic  Dermatoses. — The  reasons  for  studying 
these  together  have  just  been  stated.  Practically,  the  two  are 
inseparable.  My  object  here  is  not  to  establish  absolutely  logical 
groups  from  the  standpoint  of  general  pathology,  but  to  present 
clinical  pictures  conforming  as  closely  as  possible  to  actual  facts. 

The  atrophies  and  scleroses  are  deuteropathic  or  idiopathic. 

1.  The  deuteropathic,  generally  diffuse  forms,  with  or  without 
sclerotic  retraction  of  the  skin,  following  upon  various  grave 
dermatoses — pityriasis  rubra  of  Hebra,  malignant  herpetides,  con- 
genital pemphigus,  some  cases  of  pemphigus  foliaceus — will  not  be 
commented  on.  The  atrophy  here  is  merely  an  epiphenomenon  and 
the  dermatoses  in  the  course  of  which  they  occur  have  been  described 
elsewhere  (Chapters  VI  and  X) . 

2.  Other  scleroses  or  atrophies,  likewise  deuteropathic,  are 
entitled  on  the  contrary  to  special  consideration;  they  are  sequelae 
of  lesions  or  of  circumscribed  dermatoses,  persisting  long  after  the 
causative  affection,  which  can  sometimes  be  retrospectively  recog- 
nized through  them.    These  are  the  cicatrices  and  cicatricial  atrophies. 

3.  Next  to  them  I  place  the  linear  or  macular  atrophies,  a  hetero- 
geneous group  of  atrophies  of  variable  pathogenesis,  comprising 
protopathic  forms  and  others  which  are  deuteropathic. 

4.  A  description  of  the  idiopathic  atrophies  will  follow.  These 
curious  and  interesting  affections  are  as  yet  imperfectly  defined 
and  their  etiology  is  unknown.  A  distinction  is  made  between 
diffuse  or  regional  forms  and  other  macular  and  disseminated  forms. 

5.  Congenital  atrophies  are  very  rare.  A  generalized  form  has 
been  observed  in  degenerates,  the  offspring  of  parents  tainted  by 
alcoholism,  tuberculosis,  syphilis,  etc.  Their  integument  is  thin, 
smooth,  allowing  the  vessels  of  the  hypoderm  to  shine  through, 
pale  or  variably  pigmented,  and  extremely  vulnerable.  Partial 
congenital  atrophies,  or  atrophic  nevi,  are  more  or  less  distinctly 
outlined  spots  of  the  same  appearance,  or  yellowish  and  prominent 
through  hypertrophy  of  the  hypoderm;  they  may  assume  a  zoniform 
arrangement. 

6.  I  shall  finally  discuss  the  sclerodermas,  diffuse  and  circum- 
scribed scleroses  in  the  true  sense  of  the  term  and  which  are  still 
regarded  as  idiopathic. 


336     CUTANEOUS  ATROPHIES,  SCLEROSES  AND  DYSTROPHIES 

7.  In  another  paragraph  will  be  united  a  few  regional  dermato- 
scleroses  which  notwithstanding  the  analogy  of  their  lesions,  a 
mixture  of  atrophy  and  sclerosis,  differ  from  each  other  by  their 
localization,  their  course  and  probably  by  their  pathogenesis. 

Cutaneous  Dystrophics. — This  denomination  would  fit  a  con- 
siderable number  of  chronic  dermatoses:  Cutaneous  atrophies, 
scleroses  and  hypertrophies,  many  keratoses,  dyschromias,  folli- 
culosis,  trichoses  and  onychoses,  etc.,  really  resulting  from  a  nutri- 
tional disturbance  of  the  tissues  of  the  skin.  I  shall  limit  myself 
to  grouping  under  this  heading:  xeroderma  pigmentosum,  senile  de- 
generation, presenile  dystrophy,  and  finally  two  rare  degenerations: 
pseudo-xanthoma  and  colloid  milium. 

CICATRICES. 

A  cicatrix  consists  of  newly  developed  tissue  which  has  replaced 
a  loss  of  substance  or  followed  an  inflammatory  process.  This 
new  tissue  is  always  fibrous;  moreover,  the  reconstruction  of  the 
skin  always  remains  imperfect  for  there  is  a  lack  of  elastic  tissue, 
smooth  muscle  fibers,  hairs  and  cutaneous  glands,  often  even  of  the 
papillary  body.  A  cicatrix  may  therefore  be  said  to  be  at  the  same 
time  a  deuteropathie  dermatosclerosis  and  a  cutaneous  atrophy, 
even  when  the  scar  itself  is  hypertrophic. 

A  good  cicatrix  is  smooth,  level  or  slightly  depressed,  pink  or 
white  in  color,  supple  and  movable  on  the  underlying  tissues.  A 
vicious  cicatrix  is  uneven,  salient  or  furrowed  by  retracted  bands; 
a  keloid  cicatrix  is  the  seat  of  a  prominent  and  hard  fibrous  hyper- 
trophy. 

Very  superficial  cicatrices  are  recognized  only  by  a  very  trifling 
depression  and  a  somewhat  glistening  sheen,  with  an  altered  "grain" 
of  the  skin,  sometimes  with  dilatation  of  the  follicular  orifices; 
these  changes  being  absent  in  simple  macules. 

Thicker  cicatrices  are  at  first  rose-colored,  ultimately  white  or 
pigmented,  sometimes  scaly  and  usually  firm  on  touch.  Being  less 
extensible,  less  elastic  than  the  healthy  skin  and  often  provided 
with  a  less  active  blood  supply,  they  are  liable  to  become  the  seat 
of  tears  and  cracks,  or  they  may  be  so  highly  vulnerable  that  slight 
traumatisms  may  give  rise  to  serous  or  hemorrhagic  bullae  or 
maintain  ulcers  in  the  scars;  sometimes  they  are  tender  or  even 
spontaneously  painful.  It  is  readily  understood  that  when  the 
causative  lesions  have  involved  the  deep  parts,  bones,  muscles, 
tendons,  etc.,  the  cicatrices  may  be  adherent. 

The  origin  of  cicatrices  is  extremely  variable.  From  this  view- 
point they  may  be  divided  into  three  groups: 

J.  Those  which  are  due  to  an  artificial  loss  of  substances,  trauma- 


CICATRICES  337 

tism,  wounds,  accidental  or  surgical   incision;  a  caustic  agent,  a 
burn,  etc. 

2.  Those  which  result  from  some  ulceration. 

3.  Those  which  are  derived  from  an  interstitial  pathological 
process  without  apparent  loss  of  substance,  whose  repair  has  given 
rise  to  sclerosis  with  a  marked  change  in  the  structure  of  the  skin. 
Between  cicatrices  of  this  kind  and  what  I  shall  describe  as  cicatricial 
atrophies,  it  is  not  really  possible  to  trace  a  distinct  border-line. 

Although  no  cicatrix  is  strictly  pathognomonic  in  itself,  its  prob- 
able origin  can  often  be  surmised;  and  scars  being  indelible  consti- 
tute stigmata  of  special  value. 

In  estimating  the  symptomatic  significance  of  cicatrices,  it  is 
necessary  to  keep  in  mind  especially  their  extent,  their  number 
(variola,  acne),  their  configuration  (syphilis,  tuberculosis),  their 
seat  (bubos,  chancroids,  chancres,  lupus,  etc.),  their  depth  (ulcers, 
etc.),  and  even  their  color  (favus,  syphilis,  etc.).  It  must  be  remem- 
bered, however,  that  their  features  may  be  modified  by  various 
accessory  factors,  superadded  infections,  faulty  dressings  and  an 
unfavorable  general,  regional  or  local  territory. 

Among  the  pustular  and  ulcerative  affections  which  leave 
cicatrices,  I  shall  mention  variola,  ecthyma,  pustular  acne,  acne 
necrotica,  furuncle,  carbuncle,  ulcerative  zona,  soft  chancre;  the  mul- 
tiplicity of  cicatrices  of  this  type,  their  small  extent  and  their  locali- 
zation are  more  or  less  plainly  characteristic. 

All  tubercles,  syphilitic,  tuberculous  or  leprous,  are  almost  neces- 
sarily followed  by  cicatrices;  and  this  fact  is  implied  in  the  definition 
of  these  lesions  as  non-resolutive. 

For  simplicity's  sake,  I  shall  proceed  to  sum  up  the  features  of  the 
cicatrices  caused  by  these  three  great  infections,  independently  of 
the  original  lesion. 

In  syphilis,  the  chancre  leaves  a  cicatrix  only  when  it  has  ulcer- 
ated; actually,  in  nearly  one-half  of  the  cases. 

Ulcerative  secondary  syphilides  may  spatter  the  integument  with 
more  or  less  deep,  flat  or  honeycombed  cicatrices,  often  with  a 
pigmented  border. 

The  cicatrices  of  ulcerative  or  gummous  tertiary  syphilides  are 
said  to  be  characteristic  on  account  of  their  white  and  smooth 
appearance  with  a  zone  of  peripheral  pigmentation.  In  reality,  it 
is  their  configuration  and  arrangement  which  are  of  special  diag- 
nostic value;  they  generally  have  sharp  and  regular  contours, 
orbicular  or  semicircular,  or  are  made  up  of  disks  arranged  in  arcades, 
or  of  reniform  polycyclic  patches.  The  cicatrices  of  tubercular 
syphilides  are  often  of  irregular  surface,  honeycombed,  purplish 
or  brownish,  checkered  with  white  stars. 

The  presence  of  round  and  very  superficial  cicatrices  on  the 
22 


338     CUTANEOUS  ATROPHIES,  SCLEROSES  AND  DYSTROPHIES 

buttocks  may  be  cited  in  favor  of  n  diagnosis  of  congenital  syphilis; 
but  their  value  would  lie  very  small  in  the  absence  of  other  stigmata. 
Radiating  cicatrices  of  the  lips  are  on  the  contrary  very  charac- 
teristic in  themselves. 

The  cicatrices  of  ulcerated  tuberculosis,  bony,  articular  or  glan- 
dular, as  well  as  those  <»f  tuberculous  gummas  and  ulcers,  are  often 
distinguished  by  their  irregular,  sinuous  and  eroded  contours,  and 
their  uneven  surface,  which  presents  retracted  strands,  promon- 
tories and  bridges.  The  latter — consisting  of  minute  strands  ad- 
herent only  by  their  extremities  (under  which  horny  scales,  colored 
black  by  dust,  accumulate)  and  which  can  he  raised  by  slipping 
a  pin  underneath  possess,  I  believe  a  real  diagnostic  value  for 
tuberculosis;  but  they  are  not  absolutely  pathognomonic,  for  I  have 
-ecu  "bridged"  cicatrices  as  a  sequel  of  sporotrichotic  lesions,  of 
carbuncle  in  a  diabetic  patient,  etc. 

Lupus  leaves  very  variable  cicatrices,  according  to  its  varieties; 
flat,  white  and  smooth  in  its  erythematous  resolving  form;  thicker, 
often  rose-red,  sometimes  vicious  and  keloidal,  in  the  deep  forms. 
They  may  cause  serious  deformities  of  the  orifices  of  the  face,  for 
example  ectropion,  stricture  or  atresia  of  the  nares  and  the  mouth; 
adhesions  of  the  fingers  or  toes  (Fiji-.  170),  contractions  of  the  joints, 
etc.  They  are  frequently  the  seat  of  renewed  growth  of  lupus 
nodules. 

Leprosy  furnishes  very  variable  cicatrices,  superficial  or  deep, 
supple  or  very  sclerotic,  prominent  or  depressed,  following  upon 
bullae,  leprides  and  especially  upon  tubercles  and  infiltrations; 
they  are  often  described  as  morphoea  leprosa;  they  are  white,  or 
sometimes  deeply  pigmented  and  are  characterized  by  their  anes- 
thesia. Aside  from  these  morpheas,  mention  must  be  made  of  the 
deep  cicatrices  left  by  the  ulcers  of  leprosy  and  the  diffuse  dermato- 
<clerosis  of  the  extremities  in  the  mutilating  form 

The  vegetative  dermatoses — such  as,  Oriental  boil,  yaws,  pem- 
phigus vegetans,  iodide  and  bromide  eruptions,  etc. — also  leave 
cicatrices,  often  irregular,  with  pigmented  borders.  Needless  to 
say,  this  is  likewise  true  for  ulcers  of  all  kinds,  phagedenas,  ^an- 
grenes;  the  scars  which  follow  depend  in  the  extent,  configuration 
and  depth  of  the  original  lesions. 

The  same  remark  applies  to  tumors,  which  may  give  rise  to 
cicatrice-,  benign  tumors  like  certain  nevi  mollusci  or  absorptive 
angiomas  and  malignant  epitheliomatous  tumors.  In  this  way, 
secondary  carcinomas  of  the  skin,  ulcerated  or  not,  of  the  type 
formerly  named  scirrhus,  become  the  seat  of  a  fibrous  thickening 
which  appears  exactly  like  a  lardaceous  scleroderma.  Finally,  in 
cutaneous  epithelioma  of  the  variety  known  as  flat  cicatricial  epi- 
thelioma, the  center  of  the  patch  is  often  seen  to  become  sclerotic, 


CICATRICES  339 

the  epithelial   newformation  remaining  demonstrable   only  at  the 
borders  in  the  form  of  a  narrow  beaded  margin. 

It  is  useful  to  know  that  vice  versa  cicatrices  may  become  the 
starting-point  of  epithelioma  which  is  generally  of  the  lobulated 
type. 

The  diagnosis  of  the  origin  of  cicatrices  is  often  greatly  helped 
by  the  history,  by  serodiagnosis  and  by  the  general  examination  of 
the  patient. 

Cicatricial  Atrophies. — Alongside  of  these  often  irregular  and  im- 
portant cicatrices  which  have  just  been  discussed,  must  be  placed 
more  discrete,  usually  macular  lesions,  of  atrophic  appearance  in 
the  clinical  sense  of  the  word.  The  name  of  cicatricial  atrophies  is 
reserved  for  these  lesions. 

Cicatricial  atrophy,  generally  in  the  form  of  white,  flat,  smooth, 
more  or  less  indurated  patches,  is  the  inevitable  result  of  lupus  ery- 
thematodes  discoides,  the  different  forms  of  depilating  folliculitides, 
and  Brocq's  pseudo-alopecia;  of  the  resolutive  tuberculous  lupus; 
tubercular  syphilides  and  the  majority  of  non-ulcerating  lepromas. 

It  characterizes  a  variety  of  lichen,  known  as  lichen  planus 
atrophicus. 

Several  bullous  affections,  notably  pemphigus  congenitalis,  leprous 
pemphigus,  rarely  Duhring's  disease,  leave  spots  or  patches  of 
thinned  skin,  often  pigmented  or  purplish,  somewhat  indistinctly 
outlined. 

Small  atrophic  and  leukodermic  spots,  associated  with  pigmenta- 
tions, are  noted  in  various  dystrophies,  such  as  xeroderma  pigmen- 
tosum, senile  degeneration,  etc. 

Keratosis  pilaris,  on  healing,  leaves  behind  it  a  crop  of  punctiform 
cicatrices,  the  site  of  which  is  typical. 

Favus  very  often  produces  large,  smooth,  bald  and  cicatricial 
surfaces,  usually  of  a  pinkish  color,  but  sometimes  decidedly  white. 

Mention  must  also  be  made  of  radiodermatitis,  which  even  in  the 
absence  of  ulceration,  may  be  followed  by  white  cicatricial  atrophies 
with  diffuse  borders,  mottled  by  telangiectases  and  pigmentary 
spots. 

The  fact  that  certain  erythematous  dermatoses  terminate  in 
cicatricial  atrophy,  led  Unna  to  establish  his  group  of  ulerythema 
(from  ov\t]  =  cicatrix),  comprising  a  centrifugal  type,  lupus  erythe- 
matodes,  and  ophryogenic  and  sycosiform  types. 

This  atrophy-producing  tendency  belongs  also  to  certain  erythe- 
matous tuberculides.  Finally,  some  special  cases  of  erythema, 
urticaria  and  purpura,  have  been  known  to  terminate  in  cicatricial 
atrophies,  which  have  been  compared  with  the  idiopathic  macular 
atrophies. 

The  diagnosis  of  the  origin  and  nature  of  these  cicatricial  atrophies 


340     CUTANEOUS  ATROPHIES,  SCLEROSES  AND  DYSTROPHIES 

generally  rests  upon  their  form,  their  dimensions,  their  number,  their 
topographical  seat;  sometimes,  it  has  been  possible  to  follow  their 
development,  or  the  original  lesions  can  be  discovered,  either  at  the 
circumference  of  the  spots  or  elsewhere. 

Summarizing,  the  clinician  when  confronted  with  an  atrophic  or 
sclerotic  spot  must  think  in  the  first  place  of  a  cicatrix  and  inquire 
as  to  its  origin;  next,  if  there  is  no  genuine  cicatrix,  he  must  think 
of  the  cicatricial  atrophies;  the  processes  which  may  terminate 
in  a  lesion  of  this  nature  have  just  been  shown  to  be  extremely 
numerous  and  different;  all  possible  theories  should  be  reviewed; 
third,  when  all  the  preceding  conditions  can  be  excluded,  it  is  justi- 
fiable to  assume  an  idiopathic  macular  atrophy. 

Pathological  Anatomy. — The  pathological  anatomy  of  cicatrices 
varies  according  to  the  depth  and  character  of  the  lesions  which 
have  caused  them.  The  cutis,  or  at  least  the  papillary  body,  must 
have  been  involved,  for  otherwise  repair  would  have  occurred  with- 
out  a  scar. 

In  a  general  way,  their  structure  is  as  follows:  the  epidermis  is 
more  or  less  thick,  often  hyperkeratotic  or  parakeratotic,  smooth, 
or  sends  out  a  few  irregular  proliferations  at  its  deep  aspect,  it  covers 
a  dense  fibrous  tissue,  composed  of  parallel  connective-tissue  bundles, 
deprived  of  elastic  fibers  or  at  least  of  a  regular  elastic  network. 

The  papilla?  and  the  entire  papillary  body  are  often  missing. 
In  the  spaces  between  the  fibrous  tissue  rows  of  embryonic  or 
plasma  cells  and  often  very  numerous  mast-cells  persist  for  a  long 
time.  The  vessels,  relatively  scanty,  but  often  telangiectatic  under 
the  epidermis,  follow  variable  paths,  having  nothing  in  common 
with  the  normal  vascular  distribution.  Not  infrequently,  there  are 
collections  of  pigment  in  the  gaps  of  the  fibrous  tissue  adjacent  to 
the  epidermis,  in  the  area  or  at  the  circumference  of  the  cicatrix; 
more  rarely,  pigment  is  noted  in  the  epidermis  itself. 

The  hairs  and  pilosebaceous  follicles,  as  wrell  as  the  sweat-glands, 
are  absent  or  sometimes  transformed  into  milium  cysts. 

Treatment. —  Cicatrices  may,  in  the  course  of  time,  become  flexible 
and  resume  a  nearly  normal  color;  but  they  are  never  entirely 
obliterated. 

The  prophylactic  treatment  of  vicious  cicatrices  consists  in  the 
use  of  proper  dressings,  autoplastic  operations:  the  so-called 
epidermic  grafts  of  Reverdin,  or  dermo-epidermic  grafts  of  Ollier- 
Thiersch,  or  the  small  deep  skin  grafts  of  American  writers  may  be 
indicated  in  cases  of  extensive  loss  of  substance. 

Sometimes,  when  circumstances  are  favorable,  it  may  be  advan- 
tageous to  excise  a  disfiguring  cicatrix,  in  order  to  replace  it  by  a 
less  evident  linear  scar.  Local  massage,  sometimes  scarifications, 
often  the  application  of  mercurial  ointments  or  radiotherapy,  may 


LINEAR  AND  MACULAR  ATROPHIES  341 

improve  an  unsightly  cicatrix.  Injections  of  thiosinamin  or  fibrol- 
ysin  are  not  devoid  of  danger  and  yield  few  durable  results.  As 
regards  keloids,  this  subject  will  be  discussed  further  on. 

By  means  of  ionization  of  a  solution  of  potassium  iodide  on  the 
negative  electrode,  it  is  possible  to  liberate,  make  supple  and  bleach 
vicious  cicatrices,  even  in  longstanding  cases  (Chiray  and  Bour- 
guignon.) 

LINEAR  AND  MACULAR  ATROPHIES. 

Linear  atrophies — called-  "vergetures"  in  French,  from  their 
resemblance  to  the  livid  streaks  left  on  the  skin  by  blows  with  a 
strap  or  rod — are  also  known  as  stria?  atrophica?,  stria?  gravidarum, 
striee  distensa?,  etc. 

These  are  cutaneous  atrophies  of  elongated  form,  prominent, 
level  or  depressed,  but  always  soft  and  indentable — which  seem  to 
to  be  due  to  overstretching  of  the  skin ;  they  are  indelible,  but  often 
become  less  visible  in  the  course  of  time. 

Linear  atrophies  have  a  length  of  one  to  several  centimeters,  a 
width  of  1  to  10  mm.,  or  more,  their  form  is  elongated,  spindle- 
shaped  and  often  undulating.  Their  color,  of  a  dusky  or  bluish  red 
when  they  are  recent,  frequently  passes  into  a  pearly  white;  some- 
times, on  the  contrary,  they  are  brownish.  Their  borders  are  dis- 
tinct; their  surface  is  smooth,  or  puckered,  or  designed  in  large 
lozenges;  on  touch  they  give  a  sensation  of  softness,  of  relative 
emptiness;  as  if  a  very  thin  skin  were  resting  on  a  soft  and  yielding 
tissue. 

Almost  invariably  multiple  and  usually  symmetrical,  these  linear 
atrophies  may  develop  in  many  regions,  principally  on  the  abdomen, 
but  also  on  the  thighs,  the  loins,  above  the  knees,  on  the  flanks,  the 
breasts,  the  buttocks,  etc.  Their  direction  corresponds  as  a  rule  to 
what  are  known  as  the  lines  of  cleavage  of  the  skin ;  their  long  axis 
is  perpendicular  to  the  direction  in  which  the  maximum  tension 
which  seems  to  have  caused  them  has  taken  place ;  they  are  usually 
vertical  on  the  abdomen,  the  trochanteric  and  deltoid  regions; 
transverse  on  the  flanks,  the  loins  and  above  the  patella;  radiating 
on  the  breasts. 

Linear  atrophies  are  much  more  common  in  women,  even  outside 
of  pregnancy  (36  in  100  cases  in  adult  women,  against  6  per  cent, 
in  men,  according  to  Schultze);  although  pregnancy  is  the  most 
common  cause.  They  are  observed  in  nine-tenths  of  all  pregnant 
women  though  some  women  never  acquire  them,  even  after  ten  to 
fifteen  confinements.  Among  other  frequent  causes  of  linear  atrophies 
must  be  mentioned  obesity  and  typhoid  fever. 

In  an  endeavor  to  ascribe  a  mechanical  pathogenesis  to  these 
lesions — a  gradual  or  a  rapid  distention  of  the  skin  which  pla}Ts  an 


342     CUTANEOUS  ATROPHIES,  SCLEROSES  AND  DYSTROPHIES 

evident  but  not  exclusive  part  in  their  production  attention  has 
been  called  to  the  effects  of  growth,  anasarca,  voluminous  tumors, 
or  traumatisms. 

It  is  certain,  however,  that  another  mechanism  intervenes  aside 

from  this  distention.  As  a  matter  of  fact,  linear  atrophies  may  be 
absent  in  eases  of  enormous  aseites  or  very  large  hernias;  in  all 
probability,  there  is  no  actual  distention  of  the  skin  in  corpulent  or 
in  rapidly  growing  individuals;  linear  atrophies  may  occur  even  as  ;i 
sequel  of  emaciation,  in  typhoid  fever,  tuberculosis,  other  severe 
infections  and  certain  nervous  diseases.*  I  have  seen  linear  atrophies 
and  postsyphilitic  atrophies  coexisting  in  the  patient  shown  in  Fig. 
Ill,  who  had  lost  weight,  from  ION  to  72  kilos.  There  is  accord- 
ingly reason  to  suspect,  in  affected  individuals,  the  existence  of  a 
special  delicacy  of  the  skin,  notably  its  elastic  tissue,  either  of 
congenita]  or  toxi-infectious  origin. 

The  pathological  anatomy  of  linear  atrophies  sufficiently  explains 
their  clinical  features.  The  epidermis  and  the  papillary  body 
are  spread  out  or  folded,  the  connective-tissue  bundles  of  the 
cutis  are  parallel  and  atrophied. 

The  fundamental  lesion  consists  of  the  disappearance  of  the 
elastic  tissue  network,  the  retracted  and  shrivelled  stumps  of  which 
are  seen  on  either  side  of  the  lesion;  it  is  noteworthy  that  this 
rupture  is  not  accompanied  by  a  demonstrable  degeneration,  such 
as  a  transformation  in  elacin  of  Unna,  etc. 

Linear  atrophies  show  no  tendency  to  repair.  No  treatment  can 
guarantee  their  disappearance,  although  they  may  be  rendered  less 
apparent  by  hygiene,  hydrotherapy,  tonics.  It  is  doubtful  if  sup- 
porting appliances,  pregnancy  belts  and  so  forth,  are  of  any  use  as 
preventives,  but  their  employment  should  nevertheless  not  be 
neglected. 

Round  or  Macular  Atrophies. — This  name,  as  well  as  macules 
atrophica  or  postsyphilitic  atrophies,  designates  lesions  which  are 
entirely  analogous,  except  in  form,  with  linear  atrophies.  These 
spots  are  depressed,  level,  or  prominent,  smooth,  shrivelled,  or 
pitted,  according  to  the  state  of  tension  or  relaxation  of  the  skin, 
lavender  or  white  according  to  their  age  and  always  very  soft  and 
depressible.  They  are  round  or  oval,  punctiform  or  lenticular  and 
are  scattered  without  order,  usually  in  large  numbers  on  the  flanks, 
the  chest,  the  back,  or  the  shoulders  (  Fig.  111). 

The  relation  of  round  atrophies  to  syphilis  is  undoubted;  they 
belong  to  the  secondary  stage,  sometimes  associated  with  an  erup- 
tion of  papular  syphilides  or  with  the  pigmented  syphilide  of  the 
neck.  Their  development  could  sometimes  be  followed  as  a  sequel 
and  at  the  site  of  lenticular  papules.  There  are  cases,  however,  in 
which   the  preexistenee  of  lenticular  papules,  or  even   of  roseolar 


1D10PA  THIC  A  TROPHIES 


:;i: 


spots,  at  the  atrophic  points  cannot  be  demonstrated  and  is  posi- 
tively denied  by  the  patient. 

The  structure  is  the  same  as  that  of  linear  atrophies  and  the 
treatment  is  equally  futile. 


Fig.  111. — Round  syphilitic  atrophies  of  the  dorso-lumbar  region;  their  elevation, 
very  apparent  in  extension  of  the  trunk,  entirely  disappeared  when  the  trunk  was 
flexed  or  the  skin  stretched.  The  patient  showed,  in  addition,  linear  atrophies  on  the 
abdomen  and  the  hips. 

IDIOPATHIC  ATROPHIES. 

The  qualification  "idiopathic,"  it  is  needless  to  state,  merely 
expresses  our  ignorance  as  to  the  underlying  causes.  In  regard  to 
the  pathogenesis  of  these  atrophies,  although  they  may  sometimes 
appear  primary,  they  are  generally  supposed  to  be  the  result  of  a 
preliminary  or  concomitant  inflammatory  process.  Cases  can  be 
distinguished  in  which  this  process  is  clinically  evident  and  others 
in  which  it  is  not  demonstrable ;  but  it  is  probable  that  even  in  the 
latter  an  inflammation  is  present  in  the  first  stages  of  the  affection 
and  could  be  revealed  by  histological  examination.  On  this  view 
are  based  the  terms  dermatitis  atrophicans,  erythema  atrophicans, 
etc.,  which  have  been  suggested.  It  can  by  no  means  be  claimed 
that  the  group  of  idiopathic  atrophies  presents  a  unit,  the  contrary 
being  probably  true.  However  that  may  be,  from  the  morphological 
point  of  view,  they  may  be  divided  into  two  groups,  according  to 
their  being  diffuse  or  circumscribed. 

1 .  Diffuse  Idiopathic  Atrophies. — The  first  observations  were  made 
by  Buchwald  (1883),  Touton  and  Pospelow.  Ten  years  later,  F.  J 
Pick  described  a  type  of  this  affection  under  the  name  of  erythro- 


344    CUTANEOUS  ATROPHIES,  SCLEROSES  AND  DYSTROPHIES 

melia  and  Herxheimer  in  his  turn,  with  Hartmann,  resumed  its 
study,  under  the  name  of  acrodermatitis  atrophicans  chronica.  The 
affection  is  progressive  and  develops  in  interrupted  attacks;  but  in 
the  cases  of  Kaposi  and  of  Colombini  its  course  was  rapid.  Its 
seal  of  predilection  is  the  limbs,  but  it  may  reach  also,  or  inde- 
pendently, various  regions  of  the  trunk,  the  hips  and  even  the 
head.  The  most  distinctly  marked  clinical  type  is  described  in  the 
following: 

Erythromelia  of  Pick,  or  acrodermatitis  chronica  atrophicans  of 
Herxheimer.—  In  this  form  the  dermatosis  attacks  first  the  extremi- 
ties, more  particularly  the  dorsal  aspect  of  the  hands  and  feet  and  the 
extensor  surfaces  of  the  elbows  and  knees.  It  sometimes  seems  to 
progress  from  the  periphery  toward  the  center,  but  usually  settles 
or  markedly  predominates  in  the  above  enumerated  regions.  The 
thighs  and  arms  are  rarely  involved,  the  shoulders  and  hips  only 
exceptionally. 

The  lesion  consists  of  an  atrophy  which  may  seem  primary;  in 
other  cases,  it  is  preceded  by  a  red  edematous  infiltration  of  firm 
consistence;  from  the  hands  and  feet,  this  sclero-edematous  infil- 
tration, which  deforms  the  fingers  and  toes  and  impedes  their  move- 
ments, may  invade  the  forearms  and  legs,  often  in  the  form  of  a 
pre-ulnar  and  pre-tibial  band  with  redness  in  the  vicinity. 

The  atrophy,  primary  or  following  this  inflammatory  stage,  is 
red  or  rose-colored,  slowly  extensive  and  permanent.  The  thinned- 
out  skin,  through  which  can  be  plainly  seen  the  venous  network  and 
the  tendons,  is  nearly  alopecic,  slightly  squamous  and  puckers  like 
tissue-paper;  on  touch,  it  gives  an  impression  of  softness,  like  that 
of  moist  chamois-skin. 

Histology  shows,  aside  from  a  diminution  of  the  elastic  plexus,  an 
edematous  and  cellular  infiltration  containing  numerous  plasmocytes. 

Erythromelia  more  frequently  attacks  men  of  mature  age  than 
women.  It  lasts  for  years.  Its  ultimate  state  is  not  known;  perhaps 
a  few  cases  terminate  in  recovery. 

When  it  is  limited  to  the  hands,  it  might  be  confused  with  pella- 
grous erythema;  or  in  its  very  extensive  diffuse  form,  with  senile 
atrophy.  The  presence  of  an  edematous  inflammatory  infiltration 
at  certain  points  suffices  for  the  avoidance  of  these  errors.  Redness 
and  atrophy  serve  to  differentiate  erythromelia  from  scleroderma 
at  the  onset,  where  the  fingers  are  likewise  stiff  and  infiltrated;  but 
there  are  eases  in  which  the  two  processes  are  combined. 

In  the  poikiloderma  vascularis  atrophicans  of  Jacobi  (190!)),  or 
reticular  atrophy  of  Zinsser,  the  plexiform  atrophoderma  is  com- 
bined with  telangiectasis  and  pigmentation. 

2.  Macular  Idiopathic  Atrophies. — This  second  group  of  cases  was 
established  about  the  same  time  and  parallel  with  the  first,  although 


IDIOPATHIC  ATROPHIES  345 

with  less  certainty.  A  few  old  cases  of  cyanotic  macules  (Besnier 
and  Founder)  and  of  erythematous  atrophy  in  patches  with  periph- 
eral extension,  etc.,  were  known;  but  this  clinical  type  had  no 
scientific  standing  until  the  publication  (1891)  of  Jadassohn's  case 
of  anetoderma  erythematosum,  or  atrophia  maculosa  cutis. 

Galewski,  Nielsen,  Heuss  and  others  have  contributed  case- 
reports;  the  observation  of  Thibierge  (erythematous  atropho- 
derma) approaches  it  in  certain  respects,  while  also  offering  points 
of  contact  with  lupus  erythematodes.  But  the  cases  of  Pellizari 
(urticarial  erythema),  Balzer  (erythema  polymorphe  atrophicans), 
Hallopeau  (chronic  urticaria  with  cicatrices),  Pospelow  (purpura 
atrophicans),  Nikolsky,  etc.,  must  according  to  Heuss  be  trans- 
ferred from  the  group  of  idiopathic  macular  atrophies  to  that  of 
cicatricial  atrophies. 

It  has  been  asserted  that  macular  atrophy  represents  merely  a 
special  case,  a  circumscribed  form,  of  idiopathic  atrophy.  Certain 
observations,  due  to  Herxheimer,  Thimm  and  others,  seem  to 
establish  a  transition  between  the  two  classes.  The  objective 
differences  are,  however,  as  a  rule,  very  marked,  as  appears  from 
the  following  description. 

Macular  Atrophy  or  Anetoderma  Erythematosum  of  Jadassohn. — 
There  is  a  scattered,  more  or  less  profuse  eruption  of  atrophic  spots, 
sometimes  predominating  on  the  extensive  surface  of  the  limbs,  on 
the  flanks  and  on  the  back.  Most  commonly,  they  are  nummular 
and  rounded,  sometimes  irregular  or  even  in  strise;  their  color  varies 
from  purplish  red  to  pearly  white;  their  contours  are  distinctly 
marked  by  the  difference  in  color  and  by  the  depression  of  the 
skin  at  their  site;  on  the  least  movement,  the  epidermis  on  their 
surface  becomes  folded.  The  integument  as  a  whole  has  a  very 
peculiar  doughy  and  soft  consistence;  on  touch,  the  spots  convey 
the  impression  of  holes  dug  in  the  skin;  their  flabbiness  contrasts 
with  the  firm  consistence  of  the  atropho-sclerotic  spots  described  in 
the  next  section. 

Jadassohn  believes  he  has  shown  that  at  the  onset  the  lesion 
is  a  dermic  papule  analogous  to  a  syphilitic  papule;  others  have 
seen  spots  appearing  atrophic  from  the  start.  They  progress  slowly 
for  several  weeks  or  several  months ;  sometimes  a  rose-colored  circle 
marks  the  zone  of  invasion;  it  is  said  that  some  spots  may  completely 
disappear. 

Nearly  all  the  reported  cases  were  observed  in  young  females  who 
often  were  tainted  with  tuberculosis. 

The  differential  diagnosis  must  be  made  from  nevi  atrophici, 
from  cicatrices  and  from  cicatricial  atrophies.  I  have  observed  spots 
of  identical  appearance  in  Recklinghausen's  disease,  the  true  char- 
acter of  which  could  onlv  be  established  bv  histological  examination. 


346    CI  TANEOVS  ATROPHIES,  SCLEROSES  AND  DYSTROPHIES 


SCLEROTIC  ATROPHIES  IN  SPOTS. 

In  juxtaposition  to  the  soft  macular  atrophy,  or  anetoderma,  a 

place  must  be  assigned  to  a  clinical  picture  to  which  attention  has 
been  drawn  by  many  recent  publications.    It  consists  of  both  atrophic 

and  sclerotic  spots,  of  a  glistening,  pearly  or  porcelain  white,  level 
or  slightly  depressed,  firm  on  touch,  which  appear  in  variable  number 
in  certain  regions.  Their  dimensions  vary  in  the  same  case  from  a 
pin-head  to  a  silver  quarter,  hut  they  may  become  confluent  in 
larger  >pots. 

It  is  more  than  probable  that  this  syndrome  docs  not  constitute 
a  single  affection.  American  and  English  writers  designate  it  under 
the  name  of  White  spot  disease,  first  employed  in  1903  by  Johnston 
and  Sherwell.  It  may  he  brought  about  either  by  lichen  planus 
scleroticus  or  by  morphea  guttata.  In  a  given  case,  an  effort  must 
he  made  to  differentiate  between  these  two  affections,  on  the  basis 
of  what  will  follow.  This  is  often  impossible  and  the  question  then 
arises  if  there  is  not  another  pathological  entity  of  nearly  identical 
appearance. 

Lichen  planus  scleroticus  vel  atrophicus  (Fig.  35)  is  met  with  in 
both  sexes  and  may  be  situated  in  any  region  of  the  body,  but 
especially  at  the  nape  of  the  neck  and  on  the  wrists;  the  small  white 
spots,  finely  criss-crossed,  not  frequently  studded  with  horny  plugs, 
may  have  a  slightly  raised  border;  they  begin  as  polygonal  papules 
of  tawny  hue  and  accordingly  represent  cicatricial  atrophies.  When 
there  is  a  coexisting  ordinary  lichen  planus  on  the  integument  or 
on  the  buccal  mucosa,  this  of  course  settles  the  diagnosis.  The 
histology  of  the  lesions  shows  a  small  patch  of  subepidermic  sclerotic 
atrophy,  under  which  may  be  found,  in  recent  lesions,  a  remnant  of 
the  circumscribed  cellular  infiltration  belonging  to  lichen  planus. 
The  lichen  albus  of  Zumbrusch,  be  it  stated,  is  nothing  other  than 
this  sclerotic  lichen  planus. 

Morphcea  guttata,  or  superficial  circumscribed  scleroderma,  or  parch- 
ment-like scleroderma  ( "Kartenblattaehnliche  morphoea,"  of  Unna) 
or  white-spot  disease,  properly  so  called,  is  observed  rather  in  young- 
girls  or  women  of  any  age,  more  or  less  tainted  with  tuberculosis; 
its  seat  of  predilection  is  on  the  upper  chest,  the  shoulders,  the 
neck,  the  nape  of  the  neck  and  the  perigenital  region.  The  lesions 
which  arc  lenticular  or  nummular  with  a  tendency  to  depression, 
are  of  a  pearly  or  porcelain-white  color  and  are  bordered  by  a 
narrow  pink  or  purplish  /one;  they  may  bear  a  few  thinly  scattered 
horny  plugs;  the  sclero-atrophic  spots  originate  under  this  form  and 
may  in  all  probability  disappear;  their  number  is  very  variable. 

The  condition  represents  a  slight  hyperkeratosis,  with  a  patch 
of  compact   thickening  in  the  cutis  of  modified  staining  capacity, 


SCLERODERMA  347 

poor  in  cellular  elements;  the  preliminary  pathological  process  is 
unknown. 

Several  cases  of  white  spots  coexisting  with  scleroderma  in  patches 
or  in  bands  have  been  published;  however,  the  relationship  between 
these  two  affections  is  not  certain  for  all  the  cases,  some  authors 
have  thought  of  a  relation  with  lupus  erythematodes. 

Treatment  by  means  of  radiotherapy,  electrolysis  and  thyroid 
extracts,  seemed  to  be  beneficial  in  several  cases. 


SCLERODERMA. 

In  the  very  extensive  realm  of  the  dermatoscleroses,  the  sclero- 
dermata  form  a  limited  group  which  comprises  apparently  idiopathic 
affections,  meaning  that  their  nature  is  entirely  unknown.  They  are 
divided  into  four  groups : 

Sclerema  Neonatorum. — A  child,  born  apparently  quite  healthy, 
may  present  at  the  end  of  a  few  hours,  or  after  two  to  ten  days, 
sometimes  still  later,  a  progressive  induration  of  the  integument, 
constituting  sclerema. 

The  affection,  which  is  very  rare,  begins  at  the  posterior  portion 
of  the  lower  limbs,  reaching  the  loins,  the  back  and  the  entire  body ; 
it  may  also  begin  in  the  face. 

The  skin,  of  a  yellowish,  livid,  or  lilac  white,  is  not  depressible 
with  the  finger,  as  in  edema,  but  firm  and  cannot  be  folded.  Move- 
ments are  impeded,  the  infant  is  unable  to  take  the  breast,  emacia- 
tion is  rapid,  respiration  is  interfered  with,  the  pulse  is  slowed  and 
death  is  apt  to  supervene  in  three  or  four  days,  almost  invariably 
with  hypothermia  or  in  convulsions. 

This  disease,  which  presents  the  behavior  of  an  infectious  process 
of  indefinite  character,  differs  altogether  from  congenital  generalized 
cutaneous  atrophy.  It  has  likewise  nothing  in  common  with  fetal 
ichthyosis,  in  which  the  integument  is  red,  tense  and  covered  with  a 
carapace  of  scales. 

For  the  treatment  of  sclerema,  the  children  must  be  kept  warm  in 
the  incubator  and  fed  with  a  stomach-tube,  if  necessary.  Cures 
have  been  observed  to  follow  mercurial  inunctions. 

Generalized  Scleroderma. — This  disease,  also  named  edematous 
scleroderma  (A.  Hardy),  or  sclerema  of  adults,  or  sclerema  (Besnier), 
manifests  itself  in  two  forms: 

In  the  acute  form,  the  onset  is  sudden  and  the  course  is  rapid. 
The  patient  complains  of  stiffness,  impairment  of  movements  of  the 
trunk  and  limbs;  breathing  becomes  difficult,  the  integument  be- 
comes thickened  and  diffusely  indurated.  This  form  is  very  rare 
and  often  fatal  in  a  few  weeks,  or  at  most  a  few  months. 

The  slow  form,,  likewise  uncommon,  is  preceded  by  prodromata: 


348     CUTANEOUS  ATROPHIES,  SCLEROSES  AND  DYSTROPHIES 

disturbances  of  the  general  health,  emaciation,  febrile  attacks, 
neuralgias  and  arthralgias,  stiffening  of  the  limits,  heat  and  itching 
in  various  portions  of  the  skin,  sometimes  with  erythema,  or  local 
syncope,  or  edema,  or  secretory  disturbances,  hyperidrosis  and  so 

forth. 

Next  follows  a  sclero-edematoiis  period,  during  which  the  integu- 
ment of  the  entire  body  and  the  limits  or  of  extensive  areas  becomes 
thickened,  infiltrated  with  a  sort  of  lardaceous,  non-depressible 
edema,  with  adhesion  to  the  subjacent  tissues;  so  that  it  is  indurated, 
tense  and  cannot  be  folded.  The  color  is  a  yellowish  white,  inter- 
spersed  with  gray  or  brown  or  lilac  spots.  The  face  becomes  like 
marble,  its  folds  disappear,  movements  of  the  eyelids,  forehead  and 
lips  become  impossible;  speech  and  the  ingestion  of  food  are  ham- 
pered. The  induration  of  the  neck  and  the  chest  interfere  with 
respiration,  sometimes  with  swallowing.  The  limbs  are  stiff  or 
actually  immobilized,  more  seriously  affected  in  their  first  segments 
than  at  the  extremities.  The  boundaries  of  the  affected  regions  are 
always  diffuse. 

The  sclero-atrophic  period  gradually  follows  upon  the  preceding, 
usually  after  a  few  months.  The  skin  becomes  fibrous,  retracted,  and 
adherent  to  the  muscles  and  the  bones;  the  subcutaneous  panni- 
culus  disappears;  the  muscles  are  themselves  sclerotic  and  move- 
ments are  furthermore  impeded  by  fibrous  bands.  The  mucous 
membranes  may  be  involved.  The  patients  are  enormously  incon- 
venienced by  the  cuirass  in  which  they  are  enclosed  and  they  com- 
plain of  persistent  cold;  sensibility  is  preserved. 

Sclerema  supervenes  as  the  sequel  of  a  fall  into  cold  water,  a  severe 
traumatism,  or  an  infectious  disease.  Its  course  is  in  attacks,  with 
remissions;  death  results  most  commonly  from  pulmonary,  digestive 
or  renal  complications,  or  through  cachexia. 

Progressive  Scleroderma,  Sclerodactylia.— The  onset  here  is  on 
the  upper  extremities,  rarely  in  the  face.  This  form  is  systematized, 
symmetrical  and  progressive. 

The  first  symptoms  consist  of  nervous  and  vascular  disturbances, 
numbness,  sensations  of  cold,  spasms,  shooting  pains,  local  asphyxia 
or  local  syncope;  they  occur  in  attacks,  as  in  Raynaud's  disease, 
or  may  be  constant;  occasionally  hyperidrosis  or  pemphigoid  bullae 
have  been  noted.  These  phenomena  may  be  continued  during 
months  and  years.  Asphyxia  of  the  nose  and  ears,  and  paresthesias 
of  the  face,  have  also  been  observed. 

In  the  fully  developed  stage,  which  supervenes  at  the  end  of  several 
months  or  years,  the  fingers  become  pointed,  their  skin  is  thinned 
and  adherent  to  the  bones;  they  appear  hard  and  dry,  can  no  longer 
be  flexed  or  extended  and  are  of  a  grayish  or  slightly  livid  color. 
The  process  begins  at  the  last  phalanges,  reaching  the  root  of  the 


SCLERODERMA 


349 


fingers,  the  hands,  the  forearms,  etc.  The  fingers  transformed  into 
rigid  fusiform  sticks  may  become  the  seat  of  sluggish  ulcers  or  of 
gangrenes,  or  bony  disintegration;  terminating  in  mutilations  like 
those  of  leprosy.  The  nails  are  raised,  thinned,  or  onychogry photic. 
The  hypoderm,  the  muscles  and  tendons  participate  in  the  sclerotic 
induration,  thereby  leading  to  a  real  mummification. 

Entirely  analogous,  although  usually  less  pronounced  alterations 
occur  in  the  lower  extremities  (Fig.  112),  the  toes  become  turned  out- 


Fig.   112. — Progressive  scleroderma. 


ward;  ulcerations  and  a  certain  degree  of  plantar  keratoderma 
are  not  uncommon. 

In  the  face,  the  appearance  is  characteristic;  even  more  so  than 
in  generalized  scleroderma. 

The  wrinkles  and  folds  are  obliterated,  the  features  are  fixed  and 
immovable;  the  ears  are  rigid,  the  nose  is  pointed,  the  lips  are  thin 
and  tense,  the  eyelids  cannot  be  completely  closed,  mastication  and 
deglutition  are  impeded;  the  tongue  may  become  atrophied.  I 
have  seen  aphonia  resulting  from  an  involvement  of  the  larynx.  The 
neck,  the  chest  and  the  entire  thorax  are  finally  affected  and,  to  a 
less  degree,  the  thighs  and  the  abdomen. 

Abnormal  'pigmentations,  often  occurring  early,  form  an  integral 


351 »     '  UTANEOl  s  A  TROPHIES,  Si  'LEROSES  AND  DYSTROPHIES 

part  of  the  picture;  they  are  sometimes  diffuse  and  limited  to  the 
sclerotic  portions,  often  much  more  extensive,  macular,  mottled  or 
plexiform. 

In  a  few  rare  east's,  the  production  of  subcutaneous  calcareous 
concretions  has  been  noted,  appearing  primarily  and  predomi- 
nantly on  the  fingers  (Thibierge  and  Weissenbach,  1  * >  1 1 ).  [A  unique 
case  of  cutaneous  ossification  in  scleroderma  has  been  recorded  by 
Pollitzer,  1917.] 

The  course  is  slow,  interrupted  by  remissions;  death  is  the  result 
of  complications  or  of  cachexia;  it  may  occur  suddenly. 

Atypical  cases  have  been  noted,  beginning  with  sclero-edema  and 
accompanied  by  erythema.  The  association  of  sclero-edema  in  patches 
with  sclerodactylia  has  also  been  observed.  The  diagnosis  of  the 
clinical  form  may  present  some  difficulties  on  account  of  these  trans- 
itions which,  moreover,  justify  the  classification  of  all  sclerodermas 
in  a  single  group. 

The  differential  diagnosis  from  Raynaud's  disease  may  be  impos- 
sible at  the  onset;  although  sclerosis  of  the  skin  is  not  the  initial 
and  dominating  feature  of  this  condition,  there  occur  true  mixed  or 
intermediate  cases. 

Lepra  nervorum  is  characterized  by  anesthesia,  muscular  atrophy 
and  thickening  of  the  nerves. 

In  syringomyelia,  there  exists  a  dissociation  of  sensibility,  but  no 
true  sclerosis.  A  confusion  with  progressive  arthritis  deformans 
could  be  due  only  to  faulty  observation;  the  stiffness  and  the  deform- 
ity of  the  fingers  in  this  case  are  not  referable  to  the  condition  of  the 
>kin,  which  is  thinned  but  remains  normal.  Association  is,  however, 
possible  and  has  been  demonstrated. 

The  frequent  pigmentations  of  scleroderma  should  be  kept  in 
mind  in  order  to  avoid  confusion  with  other  melanodermas. 

Partial  Sclerodermas. — The  sclerotic  lesions  may  be  circumscribed, 
either  in  patches  with  well  defined  contours,  or  in  bands  and  in  rings. 

Scleroderma  in  Patches.  The  patches  of  scleroderma,  also  known 
;i-  morphea,  differ  from  cicatrices  by  their  spontaneous  and  primary 
appearance  as  well  as  by  their  course.  They  are  distinguished 
from  the  macular  atrophies  by  their  sclerotic  character. 

Morphea  begins  as  a  more  or  less  thickened  and  indurated, 
lilac  or  purplish  >pot.  which  slowly  increases  in  size;  at  the  end  of  a 
\\'\v  weeks  or  months  its  center  becomes  whitened  and  indurated, 
often  through  confluence  of  originally  isolated  sclerotic  points. 
According  as  the  patch  is  level,  infiltrated,  or  mammillated,  a  dis- 
tinction is  made  between  morpheas  alha  plana,  lardacea  and  tuberosa; 
hut  the  appearance  may  change  in  the  course  of  development.  I 
have  described  above     under  Morphaa  guttata,  white-spot  disease 

the  form  in  which  the  induration  resembles  parchment  and  i> 
merely  superficial. 


SCLERODERMA  351 

The  patches  of  morphea  have  a  variable  extent,  from  1  to  20 
cm.,  or  larger;  an  oval  or  irregular  shape,  with  convex  or  sinuous 
borders;  of  a  glistening,  pearly,  bluish,  or  wax-white  color.  They 
are  sometimes  spotted  with  pigment,  or  mottled  with  telangiectases, 
or  they  may  desquamate  in  large  shreds.  Their  most  characteristic 
feature  is  that  they  are  usually  bordered  by  a  zone  of  mauve,  pur- 
plish or  tawny  color,  several  millimeters  in  width,  constituting  the 
lilac  ring  of  authors.  The  consistence  of  the  patches  is  hard,  even 
woody;  they  cannot  be  folded;  sometimes  they  are  more  or  less 
closely  adherent  to  the  subjacent  layers,  the  bones  and  the  muscles. 

On  these  patches  the  hairs  have  fallen  out,  the  secretions  are 
absent,  sensibility  is  lessened  in  proportion  to  the  degree  of  the 
sclerosis;  at  the  onset,  tickling  and  itching  sensations  have  been 
noted. 

Morphea  spots  may  be  single  or  multiple,  sometimes  symmet- 
rical and  occupy  any  region  of  the  body.  They  are  not  uncommon 
in  the  face.  On  the  hairy  scalp,  confusion  must  be  guarded  against 
with  the  cicatrices  from  lupus  erythematodes  or  other  causes.  On 
the  chest,  they  must  not  be  confused  with  scirrhus  cancer.  They 
are  also  seen  on  the  abdomen,  often  on  the  limbs  and  even  on  the 
buccal  mucosa;  in  the  last  named  location,  they  assume  the  shape 
of  hard  white  spots,  which  are  retracted,  in  contradistinction  to 
leukoplakia. 

The  patches  of  morphea  after  remaining  stationary  sometimes 
for  a  very  long  time,  may  begin  to  spread;  or  they  may  give  rise 
to  obstinate  ulcers  at  points  exposed  to  injury.  Most  commonly, 
they  finally  undergo  retrogressive  changes,  the  lilac  ring  disappears, 
the  extent  of  the  patch  narrows,  its  center  shrivels,  becomes  supple 
and  covered  with  superficial  telangiectasis.  A  localized  atrophy 
is  left  behind,  known  as  morphea  atrophica.  It  is  said  that  total 
disappearance  may  occur. 

Scleroderma  in  Bands. — Instead  of  patches,  the  sclerosis  may 
form  bands,  2  to  5  cm.  wide,  with  broadening  and  narrowing  here 
and  there.  Their  length  is  variable;  they  may  extend,  for  instance, 
from  the  shoulder  to  the  hand,  or  from  the  pelvis  to  the  heel.  The 
sclerotic  band  is  prominent  or  level,  or  depressed  as  a  groove,  and 
may  impede  movements.    The  lilac  ring  is  rarely  complete. 

A  relatively  not  uncommon  clinical  type  (numerous  cases  of  which 
were  presented  at  the  London  International  Congress,  1896)  is 
is  that  of  frontal  scleroderma;  a  white  or  brownish  depressed 
sclerotic  band,  starting  from  around  the  superior  orbital  foramen, 
passes  across  the  forehead,  like  a  sabre-stroke,  terminating  more  or 
less  close  to  the  fontanelle. 

A  possible  relation  of  the  course  of  sclerodermatic  bands  with  the 
nervous,  radicular,  etc.,  territories  has  been  pointed  out;  but  these 
relations  are  irregular  and  very  inconstant  (see  linear  nevi,  p.  206). 


352    CUTANEOUS  ATROPHIES,  SCLEROSES  AND  DYSTROPHIES 

Annular  Sclerodermas.-  In  exceptional  cases,  a  band  of  sclero- 
derma has  been  seen  to  hollow  an  annular  or  semiannnlar  groove 
around  a  limb  or  around  a  finger.  The  stricture  may  produce 
edema   and   elephantiasis  below   it. 

Analogous  appearances  may  he  produced  by  two  other  affections, 
positively  distinct   from   annular  scleroderma. 

One  of  these  is  ainhum,  of  Da  Silva  Lima — or  spontaneous 
amputation  of  the  toes — which  is  endemic  in  several  colored  races 
and  begins  in  adult  life,  almost  invariably  at  the  little  toe,  which  it 
strangles  and  finally  separates. 

The  other,  known  as  congenital  amputations,  is  observed  in  all 
races,  affects  the  limbs  at  any  level  and  is  attributed  to  an  intra- 
uterine constriction  by  amniotic  bands.  Separation  is  incipient  at 
birth  and  may  become  complete  in  a  few  weeks  or  years. 

Pathological  Anatomy. -The  lesions  of  scleroderma,  no  matter  of 
what  clinical  form,  consist  of  a  thickening  with  partial  disappear- 
ance or  sometimes  a  degeneration  of  the  connective-tissue  bundles; 
the  elastic  fiber  plexus  is  preserved  and  appears  increased  as  the 
result  of  close  approximation  of  the  fibers.  It  is  not  known  if  this 
fundamental  lesion  is  the  outcome  of  an  always  identical  process. 

In  recent  cases  of  generalized  scleroderma  and  scleroderma  in 
patches,  I  have  demonstrated  a  subacute,  predominantly  peri- 
vascular inflammation  and  a  newformation  of  connective  tissue. 
The  smooth  muscles  may  be  hypertrophied.  The  vessels  were  almost 
invariably  found  to  be  affected  by  endoperiarteritis  and  phlebo- 
sclerosis;  the  peripheral  nerves  are  slightly  involved,  or  their  sheath 
i-  thickened. 

The  papillary  body  is  flattened  and  obliterated,  the  epidermis  is 
often  atrophied;  the  horny  layer  is  increased.  The  follicles  and 
glands  disappear.  Sclerosis  of  the  hypoderm  and  of  the  muscles  has 
been  described,  with  inflammation  of  the  periosteum  and  rarefac- 
tion of  the  bony  substance;  incongruous  lesions,  of  doubtful  signifi- 
cance, are  found   in  the  nerve  centers. 

In  a  case  of  generalized  scleroderma,  of  hyperacute  onset,  observed 
by  Thibierge,  I  found  the  following  changes:  in  the  sclerematous 
Stage,  ;i  thickened  epidermis,  a  tendency  to  obliteration  of  the 
papilla?,  a  condensation  of  the  papillary  body  where  the  elastic 
plexus  was  irregular  and  ravelled;  in  the  stage  of  sclerotic  atrophy, 
a  thinned  epidermis  apparently  glued  to  the  corium,  disappearance 
of  the  papillae,  a  narrow  and  sclerotic  papillary  body  supplied  with 
several  layers  of  elastic  fibers  parallel  with  the  surface;  no  sign  of  a 
cellular  infiltration. 

Etiology  and  Pathogenesis.  Scleroderma  is  more  common  in  the 
female  sex.  The  diffuse  forms  are  met  with  especially  between 
twenty  and  forty  years,  the  partial  forms,  at  uuy  age. 


REGIONAL  ATROPHIES  AND  DERMATOSCLEROSES       353 

Sudden  exposure  to  cold,  violent  emotions,  overexertion,  men- 
strual disturbances,  are  frequently  held  responsible;  the  probable 
action  of  traumatism  has  been  pointed  out  for  the  localized  and  even 
for  the  generalized  forms.  It  seems  that  several  infections  may 
play  a  part,  especially  acute  rheumatism,  typhoid  fever,  etc., 
perhaps  tuberculosis  or  congenital  syphilis.  In  a  general  way,  very 
little  is  known  concerning  the  etiology  of  the  sclerodermas. 

The  pathogenesis  is  equally  uncertain.  Vascular  lesions  are  prac- 
tically sure  to  occur.  The  effect  of  a  trophic  or  angioneurotic 
nervous  disturbance  has  been  suspected,  on  account  of  the  arrange- 
ment of  certain  sclerodermas  in  bands  and  the  common  nervous 
antecedents  of  these  patients.  Cases  where  sclerodermas  super- 
vened in  the  course  or  as  a  sequel  of  exophthalmic  goitre  have  given 
rise  to  the  thyroid  and  polyglandular  theory.  Various  infections  or 
toxic  influences  possibly  act  upon  the  nervous  system  and  the 
vascular  apparatus,  through  the  intermediation  of  functional  dis- 
turbances of  the  internally  secreting  glands.  [The  probabilities 
seem  to  me  to  indicate  that  endocrinal  disorders  are  the  most 
likely  etiological  factor.] 

Treatment. — Nearly  every  kind  of  internal  medication  has  been 
tried  in  the  diffuse  sclerodermas;  there  are  no  specifics  and  each  case 
will  have  to  be  treated  according  to  its  own  indications. 

Salicylates  have  seemed  to  be  useful  to  me;  others  have  advo- 
cated the  iodides,  arsenic  and  fibrolysin.  Successful  results  have 
been  obtained  with  thyroid  treatment,  cautiously  and  persistently 
administered,  but  are  unfortunately  not  constant. 

Aside  from  good  hygiene,  advantageous  use  may  be  made  of 
hydrotherapy,  the  continuous  current,  electric  baths,  massage,  treat- 
ment with  sulphurous  or  chlorinated  waters,  various  hot  springs  and 
mud-baths. 

In  the  partial  sclerodermas,  negative-pole  electrolysis  may  be 
recommended;  the  punctures  must  be  applied  at  considerable 
intervals  and  only  weak  currents  be  used;  ionization  has  likewise 
yielded  very  encouraging  results.  Massage,  salicylic  acid  or  salol 
ointments  are  sometimes  beneficial.  Mercurial  plasters  have  a 
classical  reputation.  Several  of  these  treatments  may,  moreover, 
be  combined. 


REGIONAL  ATROPHIES  AND  DERMATOSCLEROSES. 

In  addition  to  the  macular  sclerodermas  and  atrophies,  there 
exist  a  certain  number  of  clinical  types  in  which  the  lesions,  while 
morphologically  analogous,  are  distinctly  regional. 

Whether  they  be  related  or  not  to  the  affections  described  above, 
23 


354     CUTANEOUS  ATROPHIES,  SCLEROSES  AND  DYSTROPHIES 

the  identity  of  the  derniatological  lesion  leads  me  to  consider  them 
in  this  connection. 

Facial  Hemiatrophy. — This  affection — also  known  as  tropho- 
neurosis facialis  or  aplasia  laminaris — consists  of  a  very  marked  thin- 
ning of  the  skin  of  one-half  of  the  face,  without  sclerosis  or  adhesion. 
The  atrophy  extends  to  the  corresponding  half  of  the  palate,  the 
velum  and  sometimes  the  tongue.  The  prominences  of  the  bony 
framework  are  likewise  reduced.  The  affected  side  seems  to  be 
changed  as  if  by  old  age  and  situated  on  a  plane  behind  its  normal. 
The  skin  is  white  or  pigmented;  the  sensibility  is  intact,  but 
anidrosis  and  alopecia  are  present. 

This  Aery  rare  affection  begins  in  youth  in  the  form  of  patches 
which  gradually  spread.  Some  authors  compare  it  with  sclero- 
derma. Cases  of  coincidence  of  this  disease  with  a  scleroderma  in 
extensive  patches  have  been  reported. 

Kraurosis  Vulvae. — The  term  "kraurosis"  (Breisky),  the  meaning 
of  which  was  rather  vague,  has  been  more  accurately  defined 
especially  by  the  work  of  Jayle,  and  must  be  reserved  for  a  pro- 
gressive sclerotic  atrophy  of  the  cutaneo-mucous  tissues  of  the  vulva, 
gradually  leading  to  stenosis  of  the  vaginal  orifice,  disappearance 
of  the  labia  minora,  the  prepuce  and  frenum  of  the  clitoris  and  the 
obliteration  of  the  labia  majora.  [I  have  seen  the  process  extent 
to  the  anal  orifice.]  The  mucosa  of  the  affected  regions  is  always 
smooth,  glistening,  and  dry;  its  color  is  white,  or  red,  or  mottled. 
Complication  with  leukoplakia  is  common  and,  in  this  case,  cancer 
is  not  rare. 

The  exclusive  or  principal  pathogenic  condition  of  kraurosis 
seems  to  be  the  suppression  of  the  ovarian  functions  through  senile 
involution,  sclerotic  atrophy,  or  castration;  syphilis  seems  to  play 
a  part  in  some  cases. 

Kraurosis  must  not  be  confused  with  simple  vulvar  leukoplakia 
nor  with  the  white  coloration  of  the  vulva  through  lichenization, 
which  occurs  in  prolonged  cases  of  vulvar  pruritus.  Aside  from  treat- 
ment with  warm  irrigations  and  the  high  frequency  current,  exten- 
sive excisions  must  not  be  delayed  in  cases  of  threatened  cancer. 

Dermatoscleroses  of  the  Legs. — In  many  adults  and  in  old  people 
the  skin  of  the  legs  is  the  seat  of  very  polymorphous  but  equivalent 
pathological  changes  which  may  terminate  either  in  sclerotic  atrophy 
or  in  elephantiastic  pachyderma. 

In  the  etiology,  the  patient's  sex  is  of  small  importance;  but 
predisposing  conditions  are  represented  by  an  age  between  thirty 
and  forty-five  years,  laborious  occupations  requiring  prolonged 
standing,  repeated  pregnancies,  phlebitis,  traumatisms,  etc.  Re- 
cently, the  influence  of  syphilis  and  tuberculosis  has  been  inves- 
tigated.    The    essential    factors   seem    to   be   arteriosclerosis   and 


CUTANEOUS  DYSTROPHIES  355 

especially  varicosities.  Both  legs  are  usually  involved,  although  in 
different  degrees. 

Varicosities,  especially  the  deep  and  slightly  apparent  ones,  lead 
to  congestion  and  lowered  nutrition;  edema  and  hematic  pigmen- 
tations follow;  the  soil  is  prepared  for  complications,  varicose 
eczema,  phlebitis  and  ulcers,  which  further  aggravate  the  nutri- 
tional disturbance  by  giving  rise  to  thromboses  and  opening  an 
avenue  to  infections,  lymphangitis,  etc. 

The  resulting  dermatosclerosis,  which  is  alone  to  be  discussed  in 
this  place,  may  be  diffuse  or  circumscribed. 

In  the  former  case,  the  diffuse  form,  the  skin  is  adherent  to  the 
tibia  and  the  aponeurosis,  of  a  pasteboard-like  or  woody  hardness, 
impossible  to  raise  or  fold;  its  color  is  earthy  or  checkered  with 
purple  or  brown,  with  depressed  white  spots.  Its  surface  is  smooth, 
shining  or  scaling  and  cracked;  sometimes  it  is  covered  by  a  thick 
layer  of  dry  or  oily  brownish  crusts  under  which  may  be  found 
pinkish,  moist  or  plainly  eczematous  surfaces.  These  changes 
surround  the  entire  circumference  of  the  leg  and  extend  as  far  up 
as  the  knee;  the  foot  is  usually  merely  edematous  and  the  nails 
onychogry  photic. 

In  the  circumscribed  form,  there  exist  one  or  several  hard,  pinkish 
or  pigmented  patches,  level  with  the  skin  or  slightly  depressed, 
deeply  adherent,  often  extending  into  the  hypoderm  in  thick 
nodular  strands.  These  are  sclerotic  foci  of  periphlebitic  origin. 
A  variety  of  reticulated  sclerosis,  of  checkered  hue,  is  also  met  with, 
especially  in  the  neighborhood  of  the  ankles. 

This  dermatosclerosis  is  differentiated  from  progressive  sclero- 
derma by  its  definite  localization;  from  scleroderma  in  patches  by 
the  absence  of  a  distinct  boundary  and  a  lilac  ring;  from  the  cica- 
trices of  ulcers,  which  often  exist  at  the  same  time,  by  the  absence 
of  a  distinct  thickened  border,  which  is  characteristic  of  the  latter. 

The  efficacy  of  the  treatment  depends  upon  the  degree  and  dura- 
tion of  the  lesions.  Complete  rest  in  bed,  with  elevation  of  the 
legs,  cleanliness  and  the  dressings  required  by  the  condition  of  the 
skin,  lead  to  progressive  improvement,  which  is  often  considerable 
and  may  be  further  augmented  by  massage  and  radiotherapy. 
The  patient  must  be  instructed  to  wear  roller-bandages  or  elastic 
stockings. 

CUTANEOUS  DYSTROPHIES. 

Xeroderma  Pigmentosum. — This  dystrophy  was  first  described  by 
Kaposi  and  also  bears  the  names  of  melanosis  lenticularis  progressiva 
(Pick),  atrophoderma  pigmentosum  (R.  Croker),  and  epithelioma- 
tosis  pigmentosa  (E.  Besnier).  It  is  familial  and  of  congenital  origin, 
although  it  does  not  manifest  itself  until  the  first  years  of  childhood , 


356     CUTANEOUS  ATROPHIES,  SCLEROSES  AND  DYSTROPHIES 

The  influence  of  consanguinity  of  the  parents  has  been  shown  by 
statistics  (11.8  per  cent,  of  the  cases).  Sometimes  the  children  of 
one  sex  are  alone  affected 

The  lesions  of  xeroderma  pigmentosum,  resulting  from  an  ab- 
normal sensibility  to  light-rays,  are  essentially  regional  and  affect 
the  uncovered  regions,  face,  neck,  hands,  forearms,  sometimes  the 
legs  and  the  feet,  rarely  the  trunk. 

At  the  onset,  usually  in  the  spring  or  summer  and  after  a  solar 
erythema,  the  skin  is  seen  to  become  covered  with  lenticular  pig- 
mentary spots  of  the  appearance  and  size  of  freckles  or  larger.  It 
soon  becomes  abnormally  dry  and  peels  in  fine  lamelhe,  and  later  is 
mottled  with  telangiectases  and  atrophic  white  spots.    The  latter 


113 


erma  pigmentosum.     (Author's  photograph.) 


may  follow  upon  impetiginous  lesions  or  verrucosities,  or  originate 
spontaneously.  Finally  the  tissues  become  atrophied  and  con- 
tracted, whence  ectropion,  atresia  of  the  mouth,  thinning  of  the 
nose  and  ears,  etc.;  sometimes  conjunctivitis  and  photophobia  arc 
noted. 

The  mottled  appearance  resulting  from  atrophic  and  red  spots, 
stellate  telangiectases  and  pigmentary  spots,  is  characteristic. 

More  or  less  delayed,  often  about  the  age  of  eight  or  ten  years, 
various  new-formations  appear  upon  this  background  (Fig.  113); 
dry  verrucous  elevations,  red  and  flabby  protuberances  of  sarco- 


CUTANEOUS  DYSTROPHIES  357 

matous  or  angiomatous  appearance ;  finally,  epitheliomas  of  various 
types,  fungoid  or  ulcerative,  which  usually  result  from  the  malignant 
transformation  of  the  warty  growths.  These  various  tumors  may 
sometimes  heal ;  but,  as  a  rule,  the  epitheliomas  become  mutilating, 
involve  the  glands  and  lead  to  early  death,  usually  before  the  age 
of  twelve  years.  A  few  individuals,  however,  have  lived  to  the 
age  of  forty. 

The  patholagical  anatomy  affords  scanty  information  as  to  the 
nature  of  the  disease.  Epidermic  hypertrophy  and  atrophy  of  the 
derma  are  demonstrable;  the  various  neoplasms  mentioned  have 
their  ordinary  structure,  the  epitheliomas  are  sometimes  tubular, 
sometimes  lobulated. 

The  nature  of  xeroderma  consists  primarily  of  a  cutaneous  mal- 
formation of  the  type  of  nevic  diseases,  characterized  by  hyper- 
sensibility  of  the  skin  to  light  radiations  which  leads  secondarily 
to  a  degeneration  analogous  to  the  degenerative  changes  of  presenile 
and  senile  dystrophy,  radiodermatitis  and  arsenic  poisoning. 

The  prognosis  is  very  grave,  but  varies  with  the  severity  of  the 
case  and  the  treatment. 

The  treatment  consists  principally  in  the  avoidance  of  sunlight; 
the  covering  of  the  skin  with  protective  pastes  containing  quinine 
salts  or  aesculin;  sometimes,  it  is  useful  to  cover  it  with  masks  of 
mercurial  or  red  oxide  plaster. 

Special  care  must  be  taken  to  destroy  one  by  one,  and  very 
promptly,  the  neoplasms  which  develop,  even  the  simple  verrucosi- 
ties,  making  use  of  the  curette,  the  bistoury,  the  galvanocautery, 
caustic  agents,  or  electrolysis;  radium  has  recently  been  recom- 
mended.   Internal  medication  is  apparently  of  no  use. 

Senile  Degeneration. — The  degeneration  or  senile  atrophy  of  the 
skin,  which  regularly  occurs  at  an  advanced  age,  begins  sooner  or 
later  after  the  age  of  forty,  according  to  the  mode  of  life,  the 
general  health  and  the  heredity  of  the  individual. 

Exposure  to  inclemencies  of  the  weather  plays  a  certain  part, 
the  uncovered  portions,  like  the  face,  the  neck  and  the  back  of  the 
hands  and  wrists,  being  the  earliest  and  worst  affected;  bad  general 
and  local  hygiene,  excesses,  loss  of  sleep  and  diseases  of  all  kinds, 
also  act  as  predisposing  factors. 

Senile  degeneration  manifests  itself  as  changes  in  the  thickness 
and  color  of  the  skin,  dryness  and  a  diminished  plasticity,  which 
results  in  wrinkles. 

Two  types  may  be  distinguished  and  are  often  associated : 

The  most  common  is  simple  atrophy,  characterized  by  a  parch- 
ment-like thinning,  a  yellowish,  grayish  or  reddish  color  and  trans- 
parency of  the  skin,  rendering  visible  the  veins,  muscles,  and 
tendons,  etc.;  its  surface  is  shining  or  in  a  state  of  ichthyosiform 


358     CUTANEOUS  ATROPHIES,  SCLEROSES  AND  DYSTROPHIES 

xeroderma.  Pigmentary  or  achromic  spots,  telangiectasis  and  some- 
times purpura  senilis  arc  often  present  at  the  same  time.  Aside 
from  the  above  mentioned  regions,  the  extensor  surfaces  of  the  joints 
are  the  most  affected. 

The  second  type  is  colloid  atrophy,  in  which  the  skin  is  not  thinned, 
sometimes  on  the  contrary  thickened,  but  of  a  straw-yellow  or  old 
ivory  color,  an  uneven  surface  like  orange-peel,  soft  and  flabby, 
distended  and  folded.  This  condition  is  observed  especially  on  the 
neck  and  the  entire  face,  except  the  cartilaginous  region  of  the  nose. 

Histology  shows  as  the  principal  lesion  an  alteration  of  the 
elastic  fibers.  In  the  atrophic  type,  they  have  only  become  baso- 
philic (elacine  of  Unna)  and  the  connective  tissue  is  rarefied.  In 
the  colloid  type,  they  are  furthermore  swollen  and  perhaps  com- 
bined with  the  substance  of  the  connective-tissue  bundles  (collastine 
and  collacine).  In  this  case  there  is  found  under  the  epidermis  a 
continuous  felt-like  band,  from  I  to  §  mm.  in  width,  staining  black 
with  acid  orceine;  this  is  the  diffuse  elastoma  of  Dubreuilh  (1913). 
Several  authors  have  erroneously  confused  this  relatively  common- 
place lesion  with  pseudoxanthoma  elasticum.  The  epidermis  is 
thinned  and  hyperpigmented.  The  papilla?  are  short;  the  blood- 
vessels are  dilated  and  surrounded  by  cells.  The  glands  are  atrophied. 

Both  types  of  senile  degeneration  predispose  to  the  senile  keratoses 
which  may  lead  to  multiple  epitheliomatosis. 

The  treatment  must  be  prophylactic  and  consists  in  correct 
hygiene.  Facial  massage,  which  is  wrongfully  credited  with  the 
virtue  of  curing  wrinkles,  may  seem  useful  for  a  while,  but  is 
followed  as  a  rule  by  an  exaggeration  of  the  lesions. 

Presenile  Dystrophy. — On  the  uncovered  portions  of  the  skin, 
in  persons  exposed  to  all  kinds  of  weather,  sailors,  automobilists, 
aviators,  coachmen,  farmers,  mountaineers,  etc.,  changes  entirely 
analogous  to  those  of  xeroderma  and  even  more  so  to  those  of  senile 
degeneration  may  be  observed  after  the  age  of  twenty-five  or  thirty 
years. 

Diffuse  atrophy,  pigmentations,  cyanosis,  telangiectasis  and 
keratosis  are  met  with;  this  dystrophy  also  terminates  in  multiple 
epitheliomatosis. 

All  authors  point  out  the  striking  resemblance  often  presented 
by  the  skin  affected  with  chronic  radiodermalitis  to  that  of  xero- 
derma and  the  senile  and  presenile  dystrophies.  The  analogy  extends 
to  the  identity  of  the  epitheliomatous  complications  which  arc  here 
equally  frequent. 

Pseudoxanthoma  Elasticum. — Under  this  name  I  designated,  in 
1896,  a  rare  affection,  characterized  clinically  by  a  yellow  hue  mixed 
with  lilac,  with  thickening,  softness  and  relaxation  of  the  skin  in 
certain  regions.     It  appears  in  youthful  individuals  and  in  adults. 


CUTANEOUS  DYSTROPHIES  359 

The  changes  are  preferably  localized  in  the  vicinity  of  the  great 
articular  folds,  groins,  axillae,  bends  of  the  elbow  and  even  on  the 
neck;  it  has  never  been  observed  in  the  face.  Furthermore,  around 
the  dystrophic  surfaces  are  seen  perifollicular  spots  of  the  same 
appearance,  of  slightly  prominent,  soft,  yellowish  papules. 

However,  the  analogy  to  xanthoma  is  only  apparent.  Histologic- 
ally the  condition  is  a  degeneration  of  the  elastic  network  of  the  deep 
portions  of  the  corium;  its  fibers  swell,  proliferate,  split  and  break 
up  into  fragments.  I  have  given  to  this  special  lesion  the  name  of 
elastorrhexis. 

Certain  authors,  especially  impressed  by  the  elastic  hyperplasia, 
have  interpreted  it  as  an  elastoma  or  hamartoma,  regarding  this 
degeneration  as  a  sort  of  widespread  tumor. 

At  any  rate,  the  nature  of  the  lesions  of  pseudoxanthoma  (elastor- 
rhexis), their  seat  and  distribution,  as  well  as  the  age  at  which  the 
affection  appears,  plainly  distinguish  it  from  the  ordinary  senile 
colloid  degeneration,  or  diffuse  elastoma.  It  progresses  slowly  and 
persists  indefinitely. 

Colloid  Milium. — Also  named  miliary  colloid  degeneration  of  the 
cutis;  this  rare  dystrophy  first  described  by  E.  Wagner,  then  by  E. 
Besnier,  manifests  itself  as  translucid,  soft  yellowish  elevations, 
disseminated  or  conglomerated,  situated  on  the  face,  the  neck  and 
the  upper  limbs.  This  condition  should  accordingly  be  studied 
rather  with  the  benign  tumors  of  the  skin  (XXXI). 


CHAPTER  XVIII. 
CUTANEOUS  HYPERTROPHIES. 

Under  the  name  of  cutaneous  hypertrophy  or  pachi/derma,  I 
designate  a  persistent  increase  in  thickness  of  the  skin  as  a  whole, 
due  to  an  interstitial  fibrous  hyperplasia. 

Partial  thickenings,  affecting  the  epidermis  alone,  or  the  papillary 
body,  have  been  discussed  elsewhere  (Chapter  XI  and  XII). 

Fibrous  or  adipose  hypertrophy  of  the  hypoderm  alone,  without 
thickening  of  the  derma  does  not  belong  to  the  domain  of  derma- 
tology. 

Cutaneous  hypertrophy  is  only  very  rarely  generalized,  but  may 
be  very  extensive;  it  is  usually  regional.  The  boundaries  of  the 
change  are  almost  invariably  rather  indistinct. 

In  pachy derma,  the  skin  is  thickened  to  a  variable  degree  and 
changed  in  its  consistence.  As  a  rule,  it  is  firm,  unyielding,  or 
actually  woody;  it  is  not  at  all  or  very  slightly  depressible,  and  the 
indenting  finger  leaves  no  dimple;  it  is  incompletely  reducible  by 
compression  en  masse;  it  adheres  to  the  subjacent  tissues  and  is  not 
easily  raised  in  a  fold.  Sometimes,  however,  its  consistence  is  softer 
and  more  elastic.  The  condition  of  the  surface  and  the  color  of  the 
affected  regions  vary  greatly  in  different  cases. 

Cutaneous  hypertrophy  must  be  distinguished  from  three  related 
processes,  which  may,  moreover,  be  combined  with  it  in  variable 
degrees: 

Inflammatory  infiltration  is  due  to  deposits  of  embryonic  cells,  or 
cells  derived  from  the  blood,  in  the  tissues;  it  behaves  like  the  acute 
inflammations  or,  when  subacute,  it  is  as  a  rule  more  or  less  circum- 
scribed and  follows  a  progressive  or  a  retrogressive  course.  In  both 
cases,  however,  it  sometimes  terminates  in  hypertrophy. 

Edema,  the  result  of  a  fluid  exudate  which  infiltrates  the  tissue, 
is  depressible,  plastic,  retains  the  imprint  of  the  finger  and  is  entirely 
reducible  by  compression  en  masse,  even  in  chronic  cases.  Edemas 
of  mechanical  or  dyscratic  origin,  such  as  those  of  cardiac  or  Bright's 
disease,  etc.,  never  lead  to  pachyderma.  Inflammatory  edemas, 
on  the  contrary,  are  not  infrequently  the  starting-point  of  pachy- 
dermas,  with  which  they  are  connected  by  imperceptible  transitions, 
as  illustrated  by  the  often  used  term  of  clephantiastic  edema. 

Tumors  are  circumscribed,  heterotopic  or  hyperplastic  new- 
growths  instead  of  simple  hypertrophies.    The  question  often  arises, 


ELEPHANTIASIS  361 

however,  in  which  group  a  given  swelling  properly  belongs;  for 
instance,  an  elephantiasis  limited  to  an  eyelid  or  a  labium  majus 
may  be  mistaken  for  a  myxoma,  or  a  bunch  of  lymphatic  varicosities 
may  have  the  appearance  of  a  lymphangioma,  etc. 

Hypertrophic  Dermatoses. — The  typical  form  of  pachyderma, 
whose  clinical  features  and  lesions  conform  to  the  definition  given 
above,  is  called  Elephantiasis  arabum  (in  contradistinction  to 
Elephantiasis  grcecorum,  which  is  leprosy),  or  briefly  elephantiasis. 
It  will  be  discussed  first  in  order. 

Another  section  will  comprise  a  series  of  affections  which  I  group 
under  the  heading  of  non-elephantiastic  hypertrophies.  These  form 
a  very  heterogeneous  group.  The  differential  diagnosis  of  the 
genuine  elephantiasis  will  be  discussed  in  dealing  with  them. 

ELEPHANTIASIS. 

Elephantiasis  is  a  regional  cutaneous  hypertrophy  characterized 
by  its  course  and  its  pathogenesis. 

According  to  the  etiological  factors,  the  following  clinical  forms 
are  distinguished:  Elephantiasis  nostras;  secondary  elephantiasis; 
filarial  elephantiasis  and  congenital  elephantiasis. 

The  symptomatology  of  elephantiasis  in  general,  irrespective  of 
its  origin,  is  as  follows:  The  elephantiastic  process  begins  with 
edema,  the  inflammatory  character  of  which  is  sometimes  clearly 
evident,  sometimes  not  noticeable.  Ultimately,  a  firm  non-plastic 
tumefaction  is  established,  constituting  sclerotic  or  elephantiastic 
edema.  In  the  fully  developed  stage,  pachyderma  is  present,  com- 
bined with  a  variable  degree  of  hypertrophy  of  the  subjacent 
tissues  and  associated  with  all  the  attributes  mentioned  above. 
This  process  is  apparently  brought  about  through  the  association 
of  three  pathogenic  factors:  lymphatic  congestion,  inflammation 
and  venous  congestion. 

The  course  of  the  disease  is  intermittent;  it  is  indefinitely  pro- 
gressive and  more  or  less  extensive. 

Symptoms. — The  affected  regions  are  swollen,  tense  and  hyper- 
trophied;  their  normal  elevations  and  depressions  are  obliterated; 
sometimes,  they  are  crossed  by  deep  grooves. 

The  lower  limb,  for  example,  which  on  account  of  less  favorable 
circulatory  conditions,  is  the  chief  seat  of  election  in  elephantiasis 
assumes  the  appearance  of  a  column  or  an  elephant's  leg  (Fig.  114). 
The  integument  is  enormously  thickened  and  adherent  to  the  deep 
tissues.  Its  consistence,  which  is  that  of  a  doughy  firmness  at  the 
thigh,  usually  becomes  harder  and  more  resistant  as  it  approaches 
the  malleoli  where  it  is  sometimes  woody. 

The  surface  may  be  smooth  and  of  normal  color,  or  purplish,  or 


362 


CUTANEOUS  iiYi'Eirnioi'iiiF.s 


brownish;  again,  it  may  be  covered  with  laminated  scales,  or 
cracked  hyperkeratoses;  in  the  majority  of  the  cases,  it  is  covered 
by  more  or  less  conglomerated  verrucosities,  of  unequal  size,  rounded 
and  of  the  size  of  a  millet-seed  to  thai  of  a  cherry-pit;  or  papilloma- 
tous, acuminate  or  obtuse  and  crowded  together.  These  verrucosi- 
ties  may  l>e  pinkish  or  white,  slightly  reducible  and  translucid  like 


Fig.   114. — Elephantiasis  nostras,  consecutive  to  an  ulcer  of  the  leg. 


large  vesicles;  in  this  case,  they  are  due  to  lymphangiectases  or 
lymphatic  varicosities,  which  can  be  pricked  with  a  needle  and  yield 
a  profuse,  prolonged  flow  of  lymph  (lymphorrhea) ;  in  other  cases, 
they  are  hard,  polygonal  through  mutual  pressure  and  often  covered 
with  a  hyperkeratotic  layer,  of  dry  or  oily  consistence,  of  a  dirty 
gray  or  blackish  color.  Under  the  crusts,  as  well  as  in  the  grooves, 
a  macerated  and  fetid  epidermis  is  exposed  and  sometimes  ulcers 


ELEPHANTIASIS 


363 


are  present  having  an  irregular  outline  and  floor  with  a  sanious 
discharge. 

On  the  legs,  elephantiasis  is  unilateral  or  bilateral.  When  it  is 
caused  by  a  local  lesion,  such  as  an  ulcer  of  the  leg,  the  pachyderma 
develops  below  this  lesion,  consequently  on  the  foot.  When  the 
causative  lesions  are  situated  higher  up,  the  elephantiasis  is  on  the 
contrary  often  limited  by  the  malleoli,  forming  an  enormous  cushion 
which  is  separated  from  the  foot  by  one  or  several  deep  grooves. 
The  foot  may  retain  its  normal  volume,  but  is  usually  swollen  and 
verrucous  in  its  dorsal  region,  chiefly  near  the  toes  and  above  the 
heel. 


Fig.  115. — Elephantiasis  of  the  scrotum,  of  filarial  origin  in  an  Arab.    Case  and 
photograph  of  Dr.  Raynaud,  Algiers. 


The  thighs  are  invaded  from  below  upward,  or  consecutively  to 
elephantiasis  of  the  external  genital  organs. 

The  latter  constitute  the  second  seat  of  election  of  elephantiasis. 
In  men,  hypertrophy  of  the  sheath  of  the  penis  may  transform  this 
organ  into  a  pear-shaped  mass  20  to  40  cm.  in  length.  When  the 
scrotum  is  the  seat  of  elephantiasis,  it  may  become  as  large  as  or 
larger  than  an  adult's  head  (Fig.  115),  engulfing  the  penis;  its  surface 
is  smooth  or  verrucose.  The  name  lymph-scrotum  is  applied  to 
elephantiasis  of  the  scrotum  with  very  pronounced  lymphatic 
varicosities. 


364 


CUTANEOUS  HYPERTROPHIES 


In  women,  various  portions  of  the  vulva,  especially  the  labia 
niajora  and  minora,  or  only  one  of  these,  assume  an  enormous  size; 
the  condition  may  simulate  a  myxoma  (Fig.  116).  I  have  elsewhere 
mentioned  the  syndrome  of  esthiomene, which  maybe  brought  about 
by  a  variety  of  vulvar  ulcerations  accompanied  by  elephantiastic 
hypertrophy. 


Fig.   116. — Elephantiasis  nostras  of  the  vulva. 

In  the  groins,  elephantiasis  gives  rise  to  general  tumefaction  with 
enormous  lymphatic  dilatations,  known  as  aderto-lymphocele. 


Fig.    1  17.    -Elephantiasis  of  the  face;  elephantiastic  edema  of  the  eyelids,  following 
repeated  attacks  of  erysipelas. 


The  upper  extremities  which  are  rarely  attacked  separately,  are 
transformed  into  monstrous  sausages,  constricted  at  the  elbows 
and  the  wrists. 


ELEPHANTIASIS  365 

In  the  face,  elephantiasis  generally  appears  in  the  form  of  per- 
manent bloating,  a  flabby  but  non-plastic  edema,  usually  consecu- 
tive to  recurrent  erysipelas.  It  may  occupy  the  entire  face  and 
be  accompanied  by  lymphatic  varicosities  of  the  mouth.  In  other 
cases  it  predominates  in  a  given  region,  for  example  at  the  ears. 
The  eyelids,  especially  the  lower  lid,  may  become  the  seat  of  a 
smooth  pseudo-myxomatous  globular  swelling  (Fig.  117).  On  the 
lips,  nose  and  chin,  elephantiasis  is  usually  secondary  to  the  lesions 
of  lupus  or  leprosy,  or  especially  sclero-gummous  syphilides;  the 
resulting  facies  is  called  leontiasis. 

It  is  fairly  common,  in  all  kinds  of  elephantiasis,  for  several 
territories  to  be  invaded  at  once  or  consecutively,  for  instance  a 
lower  limb  and  the  genital  organs  or  a  leg  and  an  arm,  etc. 

At  the  borders  of  the  elephantiastic  regions,  the  transition  into 
the  normal  condition  is  always  gradual;  the  intermediate  zone  is 
edematous  and  soft. 

The  corresponding  glands  are  always  altered,  usually  indurated 
and  involved  in  the  general  swelling ;  they  may  be  impalpable  in  the 
fibro-edematous  swelling. 

Pathological  Anatomy.- — The  elephantiastic  tissues  are  tough, 
resistant  under  the  knife  or  merely  firm,  but  always  translucid,  of 
gelatinous  appearance,  gorged  with  plasma  which  escapes  abundantly 
from  the  cut  surface.  The  cutis,  the  thickness  of  which  may  reach 
2  or  3  cm.,  the  hypoderm  two  or  three  times  thicker,  with  the 
muscles  and  aponeuroses,  etc.,  form  a  single  lardaceous  mass  which 
extends  as  far  as  the  bones  which  also  are  sometimes  hyperplastic. 
The  vessels,  especially  the  veins  and  the  lymphatics,  are  seen 
gaping  in  cross-sections,  producing  a  riddled  or  cavernous  appear- 
ance. 

The  microscope  shows  in  all  cases  a  new  formation  of  young  or 
of  fibrous  connective  tissue,  without  an  elastic  plexus,  sometimes 
purely  interstitial,  sometimes  forming  besides  an  additional  layer 
between  the  corium  and  the  greatly  hypertrophied  papillae.  Between 
the  connective-tissue  bundles,  the  connective  cells  are  hyperplastic, 
sometimes  of  giant  size;  collections  of  leukocytes  and  plasmocytes 
are  also  met  with.  The  vascular  walls  are  thickened,  infiltrated 
with  cells,  or  sclerotic.  The  muscles  and  glands  are  atrophied.  The 
adipose  tissue  often  seems  to  be  increased. 

Briefly,  the  inflammatory  character  of  the  lesions  and  on  the 
other  hand  the  venous  and  lymphatic  stasis,  are  distinctly  evident; 
all  the  supporting  tissues  are  hyperplastic. 

The  corresponding  glands  are  sclerotic,  as  a  rule;  sometimes  they 
are  found  to  be  transformed  into  a  fibrous  shell,  invaded  by  fatty 
degeneration  or  into  lymphatic  cavernous  tissue.  In  secondary 
elephantiasis,  they  are  often  degenerated.     In  an  operation  upon 


3GG  CUTANEOUS  HYPERTROPHIES 

tropical  elephantiasis  of  the  scrotum,  an  adult  filaria  was  found 
in  the  excised  tissues. 

I  have  repeatedly  observed  remains  of  phlebitis  obliterans  in  the 
large  veins  supplying  the  elephantiastic  regions. 

Pathogenesis. — The  most  plausible  explanation  of  the  lesions  of 
elephantiasis  refers  them  in  the  first  place  to  stasis,  especially 
lymphatic  but  also  venous,  leading  to  edema;  and  to  a  con- 
secutive, or  rather  concomitant,  irritation  of  the  connective  tissues. 
( 'ruveilhier  particularly  stresses  the  venous  lesions,  Virchow,  the 
glandular  obstruction. 

Although  experimental  elephantiasis  cannot  be  arbitrarily  pro- 
duced, it  has  several  times  been  involuntarily  caused  in  man  through 
the  extirpation  of  a  group  of  suppurating  or  sclerotic  glands,  or 
through  paraffin  injections  which  have  obliterated  a  lymphatic 
plexus. 

Various  infections  or  neoplastic  processes  may  result  in  the  con- 
ditions essential  to  the  development  of  elephantiasis;  local  tuber- 
culosis, tertian  syphilis  and  cancer  may  become  complicated  by 
secondary  elephantiasis. 

The  relation  of  filariasis  to  the  endemic  elephantiasis  of  tropical 
countries  is  no  longer  questioned,  but  superadded  infections  may  be 
suspected  of  playing  a  certain  part  in  such  cases. 

The  relations  of  elephantiasis  nostras  to  ordinary  lymphangitis 
had  long  been  known  when  Achalme  and  Sabouraud  demonstrated 
the  presence  of  the  streptococcus  in  the  elephantiastic  tissues  in  the 
course  of  acute  attacks.  Later  it  was  shown  that  other  micro- 
organisms may  take  its  place. 

The  infection  is  exogenic  and  primary,  or  it  may  be  secondary, 
for  instance  to  ulcerative  lesions,  in  other  cases  it  seems  to  be 
endogenic,  derived  from  remote  foci,  or  lurking  for  a  long  time,  even 
indefinitely,  in  a  state  of  latent  infection  in  territories  which  have 
once  been  invaded.  Those  who  are  familiar  with  the  lymphangitic, 
phlebitic  and  glandular  lesions  of  streptococcus  and  of  erysipelas  in 
particular,  will  not  be  surprised  to  see  that  elephantiasis  may  result 
therefrom. 

Treatment. — An  acute  attack  should  be  treated,  like  all  cases  of 
lymphangitis,  by  absolute  rest,  with  elevation  of  the  affected  limb 
and  moist  dressings,  or  applications  of  ichthyol,  thiol,  etc. 

Elephantiasis  in  the  sluggish  state  must  first  be  cleansed  from  the 
crusts  and  coatings  by  means  of  baths,  fomentations,  and  oily 
inunctions;  ulcers  should  be  disinfected  and  dressed.  Next,  always 
assisted  by  rest  in  the  position  most  favorable  to  decongestion  of  the 
affected  part,  systematic  massage  should  be  employed  with  com- 
pression by  cotton-padded  bandages,  or  preferably  elastic  bandages, 
proceeding  cautiously  and  closely  watching  developments.     The 


ELEPHANTIASIS  367 

results  obtained  by  these  methods  are  sometimes  remarkable,  but 
nevertheless  as  a  rule  incomplete.  Castellani  adds  to  the  elastic 
compression,  which  must  be  kept  up  night  and  day  for  three  to  six 
months,  daily  injections  of  2  to  4  cm.  of  fibrolysin.  In  case  of 
syphilis,  specific  treatment  would  of  course  be  indicated.  Anti- 
streptococcus  serum  seems  to  be  of  slight  efficiency.  In  hard 
elephantiastic  edemas,  Denis  recommends  injections  of  "du  Breuil" 
water. 

When  sclerosis  predominates  and  compression  is  no  longer  suc- 
cessful, galvanic  electricity,  advocated  by  Moncorvo  and  Silva  da 
Araujo,  is  very  valuable  for  softening  the  indurated  tissues.  The 
negative  pole  is  represented  by  a  bath  in  which  the  affected  part  is 
placed,  or  by  moist  compresses  in  which  it  is  wrapped,  the  posi- 
tive pole  being  applied  to  the  healthy  tissues;  strong  currents  are 
required.  Still  better  results  can  undoubtedly  be  accomplished  by 
means  of  ionic  medication.  Attempts  to  perform  "lymphangio- 
plasty,"  through  subcutaneous  filiform  drainage,  are  very  variably 
estimated. 

Some  cases  of  elephantiasis,  notably  of  the  scrotum  and  penis  in 
hot  countries,  constitute  a  disease  against  which  extensive  surgical 
ablations  are  the  only  efficient  measure.  In  case  of  filariasis,  injec- 
tions of  arsenobenzol  will  cause  the  filarial  to  disappear  from  the 
blood,  but  they  do  not  seem  to  act  upon  the  elephantiasis. 

Elephantiasis  Nostras. — This  is  observed  in  adults  of  all  ages, 
and  in  both  sexes. 

In  a  considerable  number  of  cases,  the  portal  of  entrance  of  the 
infection,  usually  streptococcic,  is  obvious — a  scratch,  an  incised 
corn,  or  any  kind  of  erosion.  The  first  lymphangitis  may  be  of 
violent,  abrupt  onset,  with  edematous  and  painful  progressive 
redness,  long  red  streaks,  glandular  swelling  and  associated  febrile 
malaise.  Sometimes,  especially  in  the  face,  it  appears  as  a  typical 
erysipelas.  All  the  symptoms  subside  after  a  few  days,  but  there 
follow  repeated,  sometimes  rhythmical  recrudescences,  following 
traumatism,  fatigue,  exposure  to  cold,  or  ordinary  causes;  these 
are  often  less  violent  but  more  protracted  than  the  first  attack. 
The  tumefaction,  which  had  not  entirely  subsided  before,  becomes 
established  and  gradually  increases. 

In  other  cases,  the  initial  lesion  remains  unknown.  The  attacks 
are  afebrile  and  are  marked  only  by  heaviness  or  tenderness  of  the 
affected  region,  articular  pains,  etc.  The  lymphangitis  in  this  case 
is  not  apparent,  but  nevertheless  everything  points  to  the  occur- 
rence of  a  lymphatic  obstruction. 

Such  an  obstruction  appears  evident  in  a  third  group  where  the 
elephantiasis  develops  as  the  result  of  an  adenopathy.  Tuberculosis 
of  a  group  of  glands,  cancerous  adenopathy,  sclerotic  adenopathy 


368 


CUTANEOUS  HYPERTROPHIES 


following  upon  syphilis,  a  suppurating  glandular  in  Ha  mm  at  ion,  or 
surgical  extirpation  of  glands,  may  lead  to  elephantiasis  of  the  cor- 
responding territories.  One  of  the  lower  limbs,  or  the  genital  organs, 
or  both  these  regions  together,  will  be  involved  in  the  case  of  inguinal 
adenopathy  (Fig.  118);  the  upper  limb,  as  a  sequel  to  cancerous 
axillary  adenopathy,  which  is  so  common 
in  the  course  of  cancer  of  the  breast;  the 
face,  in  the  case  of  submaxillary  adenop- 
athy. 

Gradually,  without  inflammatory  attacks, 
the  above  outlined  clinical  picture  develops; 
lymphatic  varicosities,  lymphoceles  and 
lymphatic  fistulas  are  especially  frequent 
and  important  in  this  group  of  cases. 

Secondary  Elephantiasis  or  Elephanti- 
astic  Conditions. — This  is  by  far  the  most 
common  form  of  elephantiasis  in  our 
climates.  In  these  cases,  sclerotic  edema, 
then  elephantiastic,  usually  verrucous 
pachyderma  develop  in  connection  with  a 
local  lesion  of  which  they  represent  a  com- 
plication. 

Elephantiastic  conditions  are  observed 
in  the  course  of  cutaneous  tuberculosis  and 
especially  lupus  of  the  limbs  (elephantiastic 
lupus);  in  tertiary  syphilis,  especially  as 
the  result  of  recurrent  gummous  infiltra- 
tion on  the  limbs  or  on  the  genital  organs, 
also  at  the  circumference  of  the  mouth  and 
nose  (syphilitic  leontiasis);  in  leprosy,  when 
incurable  ulcers  are  present;  in  the  course 
of  leg  ulcers,  where  one  may  observe  the 
formation  not  only  of  a  callous  cushion, 
but  also  of  monstrous  deformities  (Fig. 
114),  above  the  ulcer  or  its  cicatrix. 

The  pathogenesis  of  these  elephantiastic 
conditions  is  often  complicated,  so  that  it 
would  not  be  justifiable  to  divide  them  into 
tuberculous,  syphilitic,  etc.,  elephantiasis. 
The  specific  process  undoubtedly  invades  the  lymphatics  and  veins 
of  the  affected  region;  but  in  addition,  the  corresponding  glands 
are  degenerated  or  sclerotic;  finally,  secondary  infection  of  the 
ulcerations  by  the  streptococcus  or  other  microbes,  whether  revealed 
or  not  through  attacks  of  lymphangitis,  is  extremely  probable  and 
can  be  bacteriologically  demonstrated  in  some  of  the  cases. 


Fig.  118.  —  Elephantiasis 
nostras  of  the  lower  limb 
with  lymphatic  varicosities 
of  the  scrotum  and  at  three 
points  on  the  thigh.  The 
lesions  in  this  young  man 
were  consecutive  to  tuber- 
cular adenopathy  of  the 
inguinal  glands.  These  de 
Guillemin,  Paris,  1900. 


ELEPHANTIASIS  369 

It  is  useful  to  know  that  after  syphilitic  chancrous  lymphangitis, 
it  is  not  uncommon  to  observe  a  sclerotic  edema  of  the  prepuce  and 
sheath,  or  of  a  labium  majus,  undoubtedly  due  to  a  specific  lymphan- 
gitis through  the  spirochete;  this  lesion  may  subside  more  or  less 
gradually  under  the  influence  of  antisyphilitic  treatment. 

Elephantiasis  Filariosa. — In  many  tropical  countries,  cases  of 
elephantiasis  are  extremely  common;  some  are  probably  referable 
to  the  various  pathogenic  factors  mentioned  above,  but  in  addition 
there  occurs  an  endemic  helminthiasis,  known  as  filariasis,  which 
may  give  rise  to  lymphangitis,  orchitis,  lymphangiectasis,  lymph 
scrotum,  filarial  abscesses,  chyluria,  chylous  hydrocele  and  also 
frequently  to  elephantiasis. 


♦  o°  o° 
oo 


J     6 


oo 


Fig.   119. — Filaria  sanguinis  hominis,  surrounded  by  red  corpuscles.     Drawn  from 
a  fresh  specimen  prepared  by  Dr.  Jolly.      X  300. 

It  is  caused  by  the  filaria  Bancrofti  and  its  embryos,  the  so-called 
microfilaria.  This  worm  is  a  nematode,  the  adult  female,  discovered 
by  Bancroft  in  1876,  measuring  8  to  10  cm.  in  length,  while  the  male 
is  considerably  smaller;  they  lodge,  a  few  in  number,  in  the  large 
lymph  trunks  or  glands,  where  the  female  hatches  innumerable 
embryos  which  resemble  small  active  eels,  about  300^  long,  from 
7  to  9^  wide,  enclosed  in  a  glassy  sheath.  These  microfilarias  were 
seen  by  Demarquay  (1863)  in  a  chylocele  and  by  Lewis  (1877)  in 
the  circulating  blood  (Filaria  sanguinis  hominis)  where  they  are 
found  only  during  the  night  and  should  be  looked  for  about  mid- 
night in  doubtful  cases;  in  the  daytime  they  withdraw  into  the 
pulmonary  vessels,  according  to  the  observation  of  P.  Manson. 

The  disease  is  transmitted  through  mosquitoes,  which  in  stinging 
the  patients  absorb  the  embryos;  these  undergo  a  metamorphosis 
in  the  thoracic  muscles  of  the  insect  and  are  then  inoculated  into 
other  human  subjects,  where  they  reach  maturity. 

The  etiological  role  of  these  parasites  in  elephantiasis  seems  to 
rest  on  the  very  frequent  association  in  the  same  countries  and 
24 


370  CUTANEOUS  HYPERTROPHIES 

in  the  same  patients,  of  monstrous  pachydermas  and  other  symp- 
toms of  filariasis.  It  must  be  admitted,  however,  that  numerous 
filaria-bearers  have  no  elephantiasis  and  that  on  the  other  hand 
in  many  elephantiasis  cases  in  hot  countries,  the  embryos  cannot  be 
demonstrated  in  the  blood. 

It  is  accordingly  possible  that  the  obstruction  of  the  large  lym- 
1  >hatic  trunks  by  the  adult  filaria,  or  of  a  large  number  of  lymph  vessels 
by  ova  which  have  not  reached  maturity  (P.  Manson),  or  the  inva- 
sion of  the  embryos  into  the  connective-tissue  interstices  of  the 
affected  parts,  are  sufficient  causes  of  the  elephantiasis;  it  is  also 
possible  that  the  filariasis  constitutes  merely  a  predisposing  cause  of 
ordinary  elephantiasis. 

At  any  rate,  filarial  elephantiasis  is  observed  in  infected  countries, 
in  all  races,  in  both  sexes,  at  all  ages,  but  especially  in  adults.  In 
95  per  cent,  of  the  cases  it  occupies  the  lower  limbs,  one  or  both; 
very  frequently  also  the  external  genital  organs.  It  proceeds  by 
lymphangitic  or  erysipeloid  attacks,  often  with  fever  (filarial  fever), 
with  general  symptoms  and  adenites,  precisely  as  in  elephantiasis 
nostras.  In  one  case,  Le  Dantec  was  able  to  isolate  and  cultivate 
a  "dermatococcus." 

The  symptomatic  shades  which  distinguish  tropical  elephantiasis 
from  the  domestic  form  consist  of  its  often  excessive  development 
and  its  frequent  association  with  enormous  lymphatic  varicosities 
or  other  filarial  manifestations. 

Congenital  Elephantiasis. — Under  this  term  are  united  a  long 
array  of  heterogeneous  cases  in  which  an  enormous  hypertrophy  of 
a  portion  of  the  body  was  demonstrated  at  birth  or  shortly  after- 
ward. There  is  reason  to  suspect  the  following  conditions,  in  differ- 
ent cases: 

Giant  lipomatosis;  diffuse  angiomas  and  lymphangiomas;  lym- 
phatic edemas  due  to  tumors  or  malformations;  and  finally,  neuro- 
fibromas or  diffuse  fibromatosis. 

According  to  Moncorvo,  who  has  made  a  special  study  of  this 
subject,  there  exists  a  genuine  fetal  elephantiasis,  due  to  intra- 
uterine lymphangitis,  the  pathogenic  agent  having  penetrated  by 
the  placental-  route.  Filaria  have  never  been  found  in  the  affected 
children. 

The  localization  is  arbitrary;  the  hypertrophy  affects  a  limb  or 
part  of  a  limb,  the  eyelids,  the  tongue,  etc. 

Congenital  macroglossia,  for  instance,  which  is  one  of  the  most 
peculiar  forms,  has  been  referred  to  a  variety  of  conditions  in  differ- 
ent cases,  fibrinous  or  muscular  hypertrophy,  cavernous  angioma 
and  especially  diffuse  lymphangioma. 

The  subject  is  complex  and  as  yet  imperfectly  understood. 


NON-ELEPHANTIASTIC  HYPERTROPHIES  371 


NON-ELEPHANTIASTIC  HYPERTROPHIES. 

Not  all  regional  or  diffuse  hypertrophies  should  be  described  as 
elephantiasis.  As  has  just  been  seen,  the  diagnosis  may  present 
serious  difficulties  in  the  newborn;  this  is  not  generally  the  case  in 
adults,  except  in  rare  cases. 

By  means  of  careful  and  systematic  palpation,  it  may  be  recog- 
nized that  there  exists  no  true  pachyderma  in  edema,  in  obesity,  in 
the  case  of  lipomas  even  when  regional  and  symmetrical,  in  adeno- 
lipomatosis,  in  adiposis  dolorosa  of  Dercum,  in  acromegaly,  etc., 
which  accordingly  do  not  belong  to  the  scope  of  this  book. 

More  closely  related  to  elephantiasis,  although  they  remain 
distinct  by  their  clinical  and  anatomical  features  and  by  their 
pathogenesis,  are  the  following  diseased  conditions: 

Nemo-arthritic  Pseudo-elephantiasis. — The  observations  to  which 
this  name,  due  to  Mathieu,  is  applied,  as  well  as  that  of  trophedema 
of  Meige  (1898)  are  difficult  to  interpret. 

Extensive  regional  edemas,  which  become  chronic  and  fibrous, 
occur  in  the  absence  of  a  demonstrable  cause;  in  other  cases,  hard, 
non-depressible  swellings  are  present  from  the  start.  The  seat  of 
predilection  of  this  affection  is  on  the  lower  limbs,  only  one  of  which 
may  be  involved,  or  both  may  be  symmetrically  swollen  and 
enlarged;  the  genitals  escape,  as  well  as  the  foot,  except  sometimes 
its  dorsal  region.  The  trophedema  may  likewise  affect  the  upper 
limbs  and  even  the  face. 

At  first  sight  the  appearance  is  that  of  elephantiasis;  but  the 
skin  always  remains  smooth,  of  normal  color,  without  verrucosities 
or  lymphatic  varices;  but  it  is  adherent,  and  cannot  be  folded  or 
indented. 

The  onset  is  often  marked  by  severe  neuralgic  pains,  or  by 
spasms,  without  inflammatory  symptoms;  exaggerated  tendon 
reflexes  were  noted  by  me  in  two  cases.  All  evidences  of  a  disease 
of  the  nervous  system  is  absent  as  a  rule. 

The  affection  progresses  or  remains  stationary,  always  lasting 
many  years  without  other  disturbance  than  an  impairment  of 
mobility;  it  may  improve  under  the  influence  of  thyroid  treatment, 
massage  and  compression,  or  sometimes  actually  disappear. 

The  pathological  lesions  are  not  well  understood.  It  is  not 
known  if  this  disease  is  comparable  to  myxedema,  constituting  an 
incomplete  or  abortive  form,  or  to  the  diffuse  hypertrophies  which 
sometimes  accompany  infantile  paralysis  or  paraplegia.  It  seems 
to  be  related  to  the  following  type: 

Neuro-arthritic  Pseudolipoma. — Potain,  Bucquoy,  Mathieu  and 
others,  have  described  under  this  name  tumefactions  having  a 
supraclavicular  and  symmetrical  seat  of  election,  supposed  to  be 


372  CUTANEOUS  HYPERTROPHIES 

angioneurotic  edemas,  plastic  at  the  onset,  then  fibrolipomatous, 
indistinctly  outlined.  Their  true  character  has  not  yet  been 
established. 

Dermatolyses. — These  malformations  are  always  partial,  usually 
congenital,  but  sometimes  developing  a  considerable  time  after 
birth.  They  consist  of  thickening  and  well  marked  loosening  of  the 
skin  in  certain  regions  of  the  body. 

Alibert  recognized  palpebral,  facial,  cervical,  ventral  and  genital 
dermatolyses;  still  others  may  be  observed,  notably  on  the  lower 
limbs.  The  denominations  pachydermatocele  (Mott)  and  chaJazo- 
derma  (Bazin)  are  less  commonly  employed. 

The  relaxed  skin  forms  large,  thick  and  flabby  folds  which  are 
dragged  by  their  own  weight  so  as  to  cover  the  subjacent  parts, 
sometimes  hanging  down  like  an  apron. 

The  majority  of  the  cases  of  this  group  are  probably  referable  to 
v.  Recklinghausen's  disease,  in  which  the  "major  tumor"  is  repre- 
sented by  the  pachydermoceie.  Swollen  and  nodular  nerve-strands 
have  been  demonstrated  therein  (plexiform  neuroma)  and  in  several 
instances  the  patients  were  at  the  same  time  the  bearers  of  smaller 
mollusca. 

Ordinary  relaxation  of  the  skin  due  to  pregnancy,  senility,  etc., 
is  not  true  dermatolysis. 

Cutis  Hyperelastica,  or  Cutis  Laxa,  is  a  different  malformation  in 
which  the  skin  of  certain  regions,  without  being  distended  or  loos- 
ened, is  of  a  doughy  consistence,  extraordinarily  distensible,  and 
suddenly  resumes  its  place  when  liberated  after  stretching.  Some 
of  the  "rubber  men,"  exhibited  in  side-shows,  can  pull  the  skin  of 
the  neck  up  to  the  forehead,  etc. 

Myxedema. — Myxedema,  or  pachydermia  cachexia,  is  a  general 
dystrophy   dependent    upon   thyroid   insufficiency. 

It  is  observed  under  a  great  variety  of  conditions,  especially  in 
women  (Gull,  Ord),  or  as  a  sequel  of  total  extirpation  of  a  goitre 
{cachexia  strumipriva,  J.  Reverdin  of  Geneva  and  Kocher  of  Bern), 
also  in  children  (myxodematous  idiocy  of  Bourneville);  the  latter, 
which  in  combination  with  goitre  constitutes  cretinism,  is  known  to 
be  endemic  in  certain  mountainous  regions. 

The  principal  symptoms  are  of  a  general  kind:  mental  sluggish- 
ness, slowness  of  movements  and  of  speech,  anorexia,  a  retarded 
pulse,  a  lowered  temperature  and  a  sensation  of  chilliness;  in 
children,  idiocy  and  an  enormous  retardation  in  growth.  Instead 
of  dwelling  upon  these,  I  shall  pass  on  to  the  external  symptoms: 

The  integument  is  swollen,  waxy  white,  dry,  scaly,  indurated  and 
docs  not  retain  the  imprint  of  the  finger.  The  hairs  fall  out,  the 
sebaceous  and   sweat   secretions  are   suppressed. 

The  appearance  is  characteristic:  the  bloated  "full-moon"  face, 


NON-ELEPHANTIASTIC  HYPERTROPHIES  373 

the  hanging  cheeks,  the  large  nose,  the  swollen  and  open  lips,  con- 
vey an  impression  of  imbecility.  The  buccal  mucosa  may  be  swollen 
and  waxy.  The  neck  is  enlarged  and  the  thyroid  gland  is  not  demon- 
strable on  palpation.  An  analogous  condition  exists  on  the  trunk 
and  especially  on  the  extremities,  which  may  present  a  pseudo- 
elephantiastic  appearance. 

The  hypothyroidism  of  the  menopause,  which  is  very  common, 
gives  rise  to  a  greatly  attenuated  picture  of  myxedema. 

The  anatomical  lesions,  aside  from  atrophy,  degeneration  or 
sclerosis  of  the  thyroid  gland,  in  the  integument  consist  of  fibrous 
proliferation,  with  hypertrophy  of  the  adipose  layer. 

I  do  not  believe  that  "  an  infiltration  of  the  tissues  by  a  substance 
analogous  to  mucin"  has  been  observed  since  Ord.  But  the  follow- 
ing have  been  demonstrated:  Collections  of  inflammatory  cells 
(Virchow),  which  I  was  enabled  to  find  also  in  experimental  myxe- 
dema in  animals;  rarefaction  with  degeneration  of  the  connective- 
tissue  bundles;  and  a  degeneration  of  the  elastic  fibers  as  in  senile 
change. 

The  treatment  with  thyroid  substance  is  imperative  and  yields 
remarkable  results,  but  must  be  kept  up  indefinitely.  Thyroid 
grafting  has  recently  been  tried. 

Rhinoscleroma. — This  is  a  progressive  hypertrophic  affection, 
described  by  Hebra  and  Kaposi,  restricted  to  the  region  of  the  nose 
and  upper  lip;  it  is  endemic  in  certain  countries,  such  as  Galicia, 
Hungary,  southwestern  Russia,  etc.,  and  is  of  microbic  origin.  [It 
is  rare  in  America  and  almost  always  of  exotic  origin.] 

The  lesions  usually  begin  on  the  septum  of  the  nasal  fossse,  or  at 
the  columella  and  the  upper  lip  in  the  form  of  solid  elevations,  with 
a  smooth  and  tense  epidermis,  of  a  red,  pink,  or  pale  color,  which 
develop  into  a  tumor  of  cartilaginous  hardness  resembling  a  keloid. 

The  disease  affects  both  nasal  fossa?,  which  become  obstructed; 
the  velum  of  the  palate,  causing  retraction  of  the  uvula;  the 
pharynx  and  larynx,  resulting  in  stenosis;  and  even  the  trachea. 

The  course  is  very  slow  and  may  lead  after  twenty  years  or  more 
to  death  from  pulmonary  complications.  The  disease  attacks 
youthful  or  adult  individuals,  especially  of  the  indigent  classes. 

An  encapsulated  bacillus,  the  Frisch  bacillus,  closely  related  to, 
if  not  identical  with  the  pneumobacillus  of  Friedlander,  is  held  to 
be  responsible  and,  it  is  claimed,  has  been  found  in  pure  culture  in 
the  glands,  which  according  to  Rona  are  frequently  swollen. 

The  lesions  consist  of  a  sclerogenic  cellular  infiltration,  containing 
large  hyaline  cells,  the  origin  of  which  is  referred  by  some  to  a 
cellular  degeneration  and  by  others  to  a  degeneration  of  the  bacilli 
themselves. 

The  surgical  treatment  is  usually  followed  by  recurrence;  caustic 


:!74 


CUTANEOUS   HYPERTROPHIES 


topical  applications  and  interstitial  injections  arc  unreliable  pro- 
cedures. Radiotherapy  is  indicated  and  has  furnished  encouraging 
results.  1 1  have  definitely  cured  one  ease  by  means  of  ./'-ray. 
Autogenous  vaccines  should  be  tried  in  eases  not  amenable  to 
radiotherapy.] 

Rhinophyma  and  Hypertrophic  Acne.  The  nose  is  sometimes  the 
seat  of  a  psendo-elephantiastie  hypertrophy,  giving  rise  to  special 
clinical  conditions  in  this  region. 

Although  without  actual  gravity  and  hardly  even  inconvenient, 
it  is  readily  understood  that  deformities  of  this  kind  are  extremely 
distressing  to  the  patients. 


§ 

: 

^P*T 

% 

''■''■  "&)wilBP^ 

■^'''^^k 

^ 

•*-£m$t-:                  §4jj^^^^ 

-Ifj^^^ 

Fie;.   120. — Acne  hypertrophica  of  the  nose. 


These  hypertrophies  of  the  nose,  more  common  in  men  than  in 
women,  do  not  occur  until  about  the  fiftieth  year  and  affect  only 
very  kerotic  individuals,  who  have  suffered  from  acne  when  young; 
often  they  are  complications  of  so-called  "  copper-nose."  The  course 
is  progressive  and  very  slow. 

Two  forms  can  be  distinguished  and  are  sometimes  associated: 
In   the  glandular  variety — or   hypertrophic  acne   of  Vidal  and 
Leloir — the  skin  is  thickened,  but  of  a  normal  color;  the  sebaceous 
pores  are  dilated  and  funnel-shaped;  the  point  of  a  probe  may  be 


NON-ELEPHANTIASTIC  HYPERTROPHIES  375 

introduced  and  a  large  amount  of  a  sebaceous,  vermicular  and  fetid 
material  squeezed  out. 

In  the  fibrous  angiectatic  variety — or  rhinophyma — the  cutaneous 
surface  is  of  a  purplish  red  color,  lumpy,  furrowed  by  large-sized 
varicose  venules,  riddled  with  sebaceous  orifices  and  often  dotted 
with  pustules. 

In  both  forms,  the  nose  is  either  uniformly  increased  in  size, 
or  covered  with  globular  protuberances  (Fig.  120)  or  even  with 
pedunculated  tumors  attached  to  the  lobule  or  the  nostrils,  some- 
times reaching  or  exceeding  the  size  of  an  egg  and  hanging  down 
to  the  chin.  Their  consistence  is  flabby,  uneven,  gelatinous.  The 
cheeks  are  sometimes  invaded  by  an  analogous  proliferation.  The 
boundaries  of  these  changes  are  not  well  marked. 

The  lesions  of  hypertrophic  acne  consist  of  an  enormous  hyper- 
trophy of  the  sebaceous  glands,  with  an  ampullary  dilatation  of 
their  excretory  duct.  In  rhinophyma,  on  the  contrary,  hyperplasia 
of  the  connective  tissue  and  of  the  vascular  and  lymphatic  plexus 
predominate.  Disseminated  foci  of  cellular  infiltration  are  regularly 
present.    Complication  with  epithelioma  has  been  repeatedly  noted. 

The  treatment  demanded  on  account  of  the  disfiguring  character 
of  these  affections  may  consist  at  the  onset  of  ichthyol  applications 
and  warm  astringent  lotions,  or  strong  sulphur  lotions,  which  in 
combination  with  massage  and  expression  of  the  sebaceous  material, 
may  improve  the  condition  of  the  affected  parts. 

It  is  preferable  to  interfere  actively,  without  loss  of  time,  by 
means  of  the  galvanocautery,  by  scarifications,  or  electrolysis. 

In  the  presence  of  a  considerable  hypertrophy,  the  operation 
known  under  the  name  of  decortication,  performed  with  the  thermo- 
cautery or  the  bistoury,  yields  excellent  results;  grafts  are  unneces- 
sary, for  the  remnants  of  the  divided  glands  become  centers  of 
epidermic  renewal ;  it  is  essential  not  to  excise  too  deeply.  Recur- 
rences have  not  been  recorded. 


CHAPTER   XIX. 
FOLLICULOSES. 

The  forms  of  dermatological  lesions  which  still  remain  to  be 
studied  in  the  first  portion  of  this  book  have  the  peculiar  feature  of 
being  characterized,  not  by  the  nature  of  the  pathological  process, 
but  by  its  localization. 

As  folliculoses  I  designate  those  pathological  processes  which 
affect  exclusively,  or  with  evident  predilection,  the  pilo-sebaceous 
follicles. 

The  syndromes  to  which  they  give  rise  assume  a  certain  appear- 
ance of  kinship  by  virtue  of  this  localization.  It  is  always  relatively 
easy,  even  for  a  beginner,  to  determine  whether  a  cutaneous  affec- 
tion is  follicular  or  not ;  it  is  far  less  simple,  when  dealing  with  a 
follieulosis,  to  distinguish  its  pathological  character.  This  con- 
sideration in  my  opinion  fully  justifies  the  arrangement  adopted 
in  the  following: 

Pilo-sebaceous  Follicles. — The  pilo-sebaceous  follicle  is  an  invagi- 
nation of  the  epidermis;  its  floor,  raised  as  a  papilla,  gives  insertion 
to  the  hair,  which  is  secreted  by  this  papilla;  a  lateral  diverticulum, 
the  sebaceous  gland,  secretes  a  fatty  material,  the  sebum. 

This  follicle,  of  epithelial  structure,  projects  into  the  derma,  its 
extremity  sometimes  reaching  the  hypoderm.  It  is  encased  in  a 
fibrous  follicular  sac,  into  which  a  muscle  with  smooth  fibers,  the 
erector  pill,  is  usually  inserted. 

Two  details  in  the  structure  of  the  follicle  are  of  special  interest 
for  the  dermatologist. 

The  first  concerns  the  difference  in  its  constitution  above  and 
below  the  opening  of  the  sebaceous  gland.  Whereas  in  the  deep 
portion  the  invaginated  epidermis  undergoes  various  modifications 
which  transform  it  into  the  epithelial  sheaths  of  the  hair,  it  pre- 
serves in  the  external,  less  extensive  portion,  exactly  the  same  char- 
acteristics as  on  the  surface  of  the  skin.  This  superficial  portion, 
the  follicular  collar,  also  known  as  the  ostium  of  the  follicle,  the  pore, 
or  on  account  of  its  usual  form,  the  follicular  funnel,  participates 
therefore  in  the  pathology  of  the  surface  epithelium. 

Moreover,  the  follicular  pore  is  especially  exposed  to  repeated 
traumatism,  through  rubbing  and  scratching,  because  the  hair 
which  traverses  it  acts  as  the  arm  of  a  lever. 

Finally,  it  represents  an  ever-ready  receptacle  for  dust,  irritative 


ACUTE  SUPPURATIVE  FOLLICULI TIDES  377 

matter  of  occupational,  pathological  or  therapeutic  origin  and 
notably  for  microorganisms,  pathogenic  or  saprophytic,  to  which 
it  offers  shelter.  It  has  very  properly  been  said  that  the  follicular 
funnel  is  the  flaw  in  the  epidermic  armor. 

Another  noteworthy  anatomical  fact  is  that  the  pilo-sebaceous 
follicle  is  surrounded  by  a  network  particularly  rich  in  bloodvessels 
and  nerves;  with  the  result  that  the  phenomena  of  reaction  are 
easily  elicited  and  well-marked. 

The  pilo-sebaceous  follicles  are  distributed,  in  variable  numbers 
and  dimensions  in  different  regions,  over  the  entire  integument, 
with  the  sole  exception  of  the  palmar,  plantar  and  ungual  regions 
and  the  semimucosse.  It  is  therefore  an  incorrect  expression  to 
speak  of  areas  provided  with  fine  downy  hairs  as  glabrous  or  smooth, 
in  contradistinction  to  hairy  regions  supplied  with  coarse  hairs. 

Folliculoses. — The  affections  of  the  follicles,  which  I  group 
under  this  heading,  are  very  numerous  and  variegated.  Some  con- 
cern the  localization  of  a  skin  disease  which  occurs  elsewhere,  while 
others  are  pathological  conditions  peculiar  to  the  follicles. 

In  the  former  case,  the  follicular  localization  may  be  accidental, 
as  it  were,  without  lending  a  special  feature  to  the  dermatosis; 
this  is  the  case,  for  instance,  in  follicular  purpura,  in  psoriasis,  in 
soft  chancre,  etc.  It  seems  to  me  superfluous  to  dwell  upon  these 
possible  peculiarities. 

In  other  cases,  the  follicular  localization  of  the  dermatosis  is  elective 
and  visibly  modifies  the  clinical  picture;  the  affections  of  this  kind 
(for  example:  follicular  pyodermatitides,  follicular  syphilides,  etc.), 
must  necessarily  figure  in  this  chapter. 

However,  the  preceding  data  do  not  furnish  a  sufficient  basis  of 
classification.  The  mode  of  grouping  the  folliculosis  which  seems  to 
me  most  in  conformity  with  clinical  facts,  distinguishes  between : 

1.  Acute  suppurative  folliculitides. 

2.  Follicular  complications  of  kerosis,  namely  seborrhea  and  the 
various  acnes  which  result  from  the  same. 

3.  Depilating  folliculoses. 

4.  Subacute  folliculoses ,  among  which  belong  the  follicular  locali- 
zations of  eczematides,  syphilides  and  tuberculides. 

5.  Pityriasis  rubra  pilaris,  which  one  is  inclined  at  present  to 
connect  with  the  preceding  group. 

6.  Follicular  keratoses. 

ACUTE  SUPPURATIVE  POLLICULITIDES. 

These  are  subdivided  into  two  groups:  those  which  are  purely 
pyococcic,  namely  due  to  the  ordinary  microbes  of  suppuration; 
and  those  which  are  trichophytic. 


378  FOLLWULOSES 

They  manifest  themselves  in  the  form  of  pustules  pierced  by  a 
hair  through  their  center,  more  or  less  superficial  or  deep,  of 
variable  size  and   surrounded  by  a  congestive  halo. 

It  has  been  shown  above  that  Bockhardt's  impetigo  or  staphylo- 
coccic impetigo,  tends  to  assume  the  form  of  superficial  and  intra- 
epidermic  osteofollicular  pustules;  it  is  unnecessary  to  repeat  its 
description. 

Not  uncommonly  the  superficial  suppuration  is  accompanied  or 
complicated  by  the  formation  of  a  minute  abscess,  situated  more 
deeply  along  the  follicle  and  due  to  the  penetration  of  the  pyogenic 
microbe  (Plate  II):  this  condition  is  notably  present  in  the  case  of 
folliculitides  of  the  regions  with  coarse  hairs,  known  under  the  old 
name  of  .sycosis  (from  gvkov  =  ?l  fig.).  There  are  two  varieties  of 
sycosis:  one  simple  or  pyococcic,  the  other  trichophy tic ;  the  latter 
will  be  described  together  with  the  trichophytic  folliculitides. 

Furuncle  and  carbuncle  are  acute  staphylococcic  folliculitides,  deep 
from  the  start,  with  extensive  inflammation,  terminating  in  partial 
necrosis  and  suppuration.  The  primary  follicular  localization,  some- 
times very  apparent,  is  less  evident  in  other  cases.  The  reader  is 
referred  for  their  description  to  the  chapter  on  the  pyodermati- 
tides. 

Acnes  are  often  pustules,  but  they  represent  the  inflammation  of 
a  preliminarily  altered  follicle  and  will  be  discussed  in  a  subsequent 
section . 

Sycosis  Simplex. — The  acute  suppurative  staphylococcic  follic- 
ulitis of  hairy  regions,  more  particularly  the  beard,  give  rise  to  a 
symptom-complex,  commonly  designated  under  the  name  of  sycosis 
simplex,  vulgaris,  or  non-parasitic,  in  contradistinction  to  tricho- 
phytic sycosis. 

Aside  from  the  moustache  and  the  beard,  simple  sycosis  is  met 
with  at  the  pubis  and  in  the  axilla?  in  both  sexes  and  on  the  hairy 
seal])  in  children. 

The  peripilar  pustules,  deep  from  the  start  or  becoming  so  later, 
are  scattered  irregularly  or  they  may  be  agminated.  Sometimes  they 
begin  as  follicular  papules  or  as  tuberous  elevations  or  as  more  or 
less  deep  and  extensive  soft  infiltrations,  causing  a  sensation  of 
tension,  heat  or  shooting  pains  and  suppurating  only  secondarily; 
often  the  suppuration  is  primary  and  early.  The  affected  regions 
become  covered  with  yellowish  or  brownish  crusts,  under  which 
the  skin  is  reddened,  eroded  and  thickened;  pressure  upon  them 
causes  pus  to  escape  from  the  enlarged  follicular  orifices. 

A  long  while  before  falling  out  spontaneously  the  hairs  can  be 
pulled  out  easily  and  painlessly  with  forceps  or  with  the  fingers; 
they  come  out  with  their  root  surrounded  by  a  gelatinous,  trans- 
lucid  or  opalescent  sheath,  which  is  their  epithelial  sheath  infil- 


ACUTE  SUPPURATIVE  FOLLICV LI TIDES  379 

trated  with  pus.  This  sign,  which  is  typical  of  an  involvement  of 
the  deep  portion  of  the  follicle,  is  absent  in  osteofollicular  impetigo ; 
it  suggests  that  the  papilla  may  be  destroyed  by  the  suppuration, 
with  the  result  of  permanent  alopecia,  although  this  is  usually  not 
the  case. 

Simple  sycosis,  following  upon  impetigo,  furuncle,  panaris,  coryza 
or  an  infection  by  means  of  the  razor,  is  spread  from  one  place  to 
another  and  carried  to  a  distance  by  means  of  the  fingers  or  toilet 
articles  [especially  towels].  The  deep,  intradermic  seat  of  the 
affection,  moreover,  renders  it  rather  inaccessible  to  therapeutic 
agents,  which  explains  its  obstinate,  frequently  chronic  character 
and  its  tendency  to  recurrence.  Cases  of  sycosis  of  the  beard  of 
many  months'  or  even  years'  standing  are  met  with. 

The  topography  of  the  lesions  permits  a  separation  into  several 
clinical  types: 

Sycosis  of  the  beard  (mentagra  of  Alibert),  usually  symmetrical, 
occupies  the  lower  portion  of  the  cheeks,  whence  it  spreads  upward 
toward  the  temples  and  downward  to  the  subhyoid  region,  some- 
times reaching  the  chin. 

Sycosis  of  the  mustache,  often  situated  laterally  under  one  nostril 
before  becoming  bilateral,  is  practically  always  connected  with  a 
lesion  or  infection  of  the  corresponding  nasal  fossa.  This  mani- 
fests itself  by  chronic  coryza,  a  habitual  mucous  or  mucopurulent 
nasal  discharge  and  ordinarily  gives  rise  at  the  same  time  to  follic- 
ulitis of  the  nasal  fossae  and  ciliary  blepharitis  or  phlyctenular 
conjunctivitis  through  an  ascending  infection.  It  is  noteworthy 
that  trichophytic  sycosis,  on  the  contrary,  is  extremely  rare  in  the 
region  below  the  nostrils. 

The  beard  and  moustache  may  be  invaded,  as  a  whole,  in  stru- 
mous or  exhausted  individuals,  convalescents  from  serious  diseases 
or  even  in  apparently  healthy  men  in  whom  all  pus  infections  find 
an  especially  favorable  soil  and  tend  to  last  indefinitely  in  conse- 
quence of  an  unexplained  predisposition. 

In  the  pubic  or  axillary  region  the  suppurative  folliculitides 
develop  especially  under  cover  of  uncleanliness  and  neglect  and 
sometimes  after  scabies.  Often,  as  also  in  the  case  of  the  beard, 
they  become  superimposed  on  a  seborrheic  or  artificial  eczema. 

The  condition  sometimes  described  as  eczema  pilaris  is  merely 
an  eczema  of  the  hairy  regions  complicated  by  a  peripilar  impeti- 
ginization  or  by  staphylococcic  folliculitis. 

On  the  hairy  scalp  the  folliculitides  are  observed  chiefly  in  school- 
children. Pediculosis  and  various  traumatisms  are  common  caus- 
ative factors.  There  may  be  a  rapid  and  profuse  outbreak  of  sup-- 
purative  folliculitis  over  a  part  of  the  scalp  or  over  the  entire  scalp, 
as  the  sequel  of  removal  of  hairs  with  the  forceps,  painting  with 


380  FOLLICULOSES 

iodin  tincture,  application  of  salves,  etc.,  in  the  course  of  treatment, 
for  instance,  of  an  attack  of  tinea. 

The  treatment  of  sycosis  vulgaris  is  likely  to  be  tedious.  In  the 
first  place  the  diagnosis  must  have  been  positively  confirmed  by 
the  microscopic  examination  of  the  hairs,  showing  the  absence  of 
the  trichophyton. 

The  rule  is  to  stop  the  use  of  the  razor,  to  cut  the  hairs  short  with 
scissors,  to  clean  the  crusted  surfaces  with  sprays  or  moist  dres- 
sings, to  pull  out  the  hairs  which  are  easily  detached,  to  empty  the 
pustules  and  pack  them  several  times  daily  with  absorbent  cotton 
soaked  in  "eau  d'Alibour"  or  in  resorcinated  or  camphorated 
alcohol. 

At  the  onset,  starch  poultices  are  better  tolerated  than  salves  or 
pastes  containing  calomel,  yellow  oxide,  ichthyol,  sulphur,  salicylic 
acid  or  resorcin,  etc.,  which  may  be  indicated  later  on. 

Total  epilation  is  sometimes  indispensable,  notably  when  the 
suppuration  has  reached  the  depth  of  the  follicle.  Preliminary 
radiotherapy  greatly  facilitates  this  and  by  itself  alone  often  acts 
very  favorably,  even  in  weak  doses. 

In  obstinate  cases,  vaccinotherapy  is  often  advantageously 
employed,  either  with  stock  staphylococci  or  with  an  autogenous 
vaccine.  Good  results  are  sometimes  obtained  through  the  appli- 
cation of  zinc  pastes  with  oil  of  cade  and  sulphur  or  with  ichthyol 
(5  per  cent.)  containing  resorcin  (3  to  5  per  cent.). 

In  the  terminal  stage,  mercurial  plasters,  sometimes  scarifications 
and  the  x-rays  are  effective  in  the  obliteration  of  the  indurations. 
Correction  of  hygienic  conditions  and  general  tonic  treatment  must 
not  be  neglected;  beer-yeast,  ferments,  arsenic  and  sulphur  water 
may  be  of  use. 

It  is  needless  to  say  that  from  the  start  everything  must  be  done 
to  extinguish  the  original  foci  of  the  pyococcic  infection  and  especi- 
ally to  cure  the  chronic  coryza  in  cases  of  sycosis  of  the  moustache. 

Trichophytic  Folliculitides. — The  trichophytons  which  cause  sup- 
purative follicular  inflammations  are  ectothrix  trichophytons,  that 
is,  they  vegetate  in  the  sheath  of  the  hairs  and  not  or  very  slightly 
in  their  interior.  Adults  are  rather  more  susceptible  than  children. 
The  parasites  are  directly  or  indirectly  of  animal  origin. 

Several  clinical  types  of  these  trichophytic  folliculitides  may  be 
described: 

Sycosis  trichophytica  barbce  is  due,  in  the  majority  of  cases,  to  the 
trichophyton  of  horses  (trichophyton  gypseum);  it  grows  in  white 
cultures  and  is  in  itself  highly  pyogenic.  It  gives  rise  to  peripilar 
pustules,  with  a  fairly  intense  inflammatory  zone  and  a  rapidly 
swelling  base;  they  become  agglomerated  in  red  and  raised,  tuber- 
ous, firm   or  even   indurated   patches   or  masses  from   which  pus 


ACUTE  SUPPURATIVE  FOLLICU  LIT  IDES 


381 


escapes  through  numerous  orifices  on  pressure;  sometimes  purulent 
sloughs  occur.  These  patches  gradually  extend  peripherally  and 
new  regions  at  a  distance  are  attacked.  The  hairs  in  the  middle 
of  the  patch  easily  come  out  with  the  forceps  and  are  denuded  and 
dead;  it  is  necessary  to  look  at  the  margins  for  hairs  still  provided 
with  their  root-sheath,  where  it  is  easier  to  find  the  parasitic  spore- 
bearing  mycelium  under  the  microscope. 

The  lesions  are  preferably  situated  in  the  lower  portion  of  the 
cheeks  or  the  chin,  sometimes  at  the  temples  or  in  the  hyoid  regions 
(Fig.  121) ;  they  are  often  asymmetrical;  in  one  case  I  found  them  on 
the  moustache,  an  absolutely  exceptional  location. 


Fig.   121. — Tri exophytic  folliculitis  of  the  beard;  parasitic  sycosis  due  to  tricho- 
phyton ectothrix.     After  a  cast  in  the  Museum  of  the  St.  Louis  Hospital,  Paris. 


Trichophytic  sycosis  is  observed  especially  in  coachmen,  grooms, 
knackers,  veterinaries  and  horseshoers. 

Trichophytosis  of  the  beard  may  assume  other  aspects;  that  of 
drier,  less  suppurative  papules  or  tuberosities;  that  of  red  circles 
or  arcs,  with  white  scales  and  dry  epidermic  plugs,  from  which  a 
broken  hair  emerges,  suggestive  of  keratosis  pilaris,  etc.  This  is 
undoubtedly  due  to  a  difference  of  the  trichophytic  species;  as  a 
matter  of  fact,  a  bird  trichophyton  with  rose-colored  cultures  has 


382  FOLLICULOSES 

been  demonstrated,  a  yellow  species,  the  acuminatum,  the  viola- 
ceum  and  so  forth. 

Kerion  Celsi  is  the  name  applied  to  patches  of  trichophytosis 
occupying  the  hairy  scalp  of  children  or  adults  and  similar  to  those 
described  above  in  the  beard;  they  are  likewise  generally  due  to 
the  trichophyton  gypseum. 

The  condition,  as  a  rule,  consists  of  one  or  several  nummular  or 
larger,  distinctly  elevated,  rounded  disks,  with  sharply  outlined 
borders  of  a  bright  red  color;  the  hairs  have  fallen  or  are  easily 
detached;  there  is  a  scattering  of  small  white  pustules  which  can 
be  emptied  by  pressure. 

Folliculitis  Agminata,  or  Leloir's  folliculite conglomeree en  placards, 
is  the  same  affection  as  kerion,  but  occupies  the  smooth  parts. 
It  is  observed  at  all  ages,  on  the  wrists,  the  forearms  and  the  neck. 
The  red  patch,  comparable  with  a  macaroon,  is  covered  with  a 
crust  or  with  thick  pus;  after  it  has  been  cleansed  it  appears  inter- 
spersed with  dilated  follicular  orifices  which  riddle  it  like  a  sieve. 
There  may  be  several  patches  of  different  ages.  Their  growth  is 
rapid  and  takes  place  in  a  few  days. 

The  spores  and  fragments  of  the  mycelium  are  often  difficult  to 
demonstrate  in  the  pus,  so  that  the  nature  of  this  affection  was  not 
recognized  by  Leloir.  Like  kerion,  it  sometimes  lasts  for  weeks 
and  months,  but  it  may  disappear  spontaneously. 

The  suppurative  trichophytic  folliculitides  leave,  as  a  rule,  more 
or  less  alopecic  cicatrices. 

The  diagnosis  can  sometimes  be  based  on  the  clinical  charac- 
ters alone,  but  should  always  be  confirmed  by  microscopic  exami- 
nation and  if  possible  by  culture.  The  pyococcic  folliculitides, 
even  when  agminated,  do  not  form  as  distinctly  circumscribed 
round  patches  and  are  more  apt  to  be  disseminated.  Furuncle 
and  carbuncle  have  a  more  pronounced  and  extensive  inflammatory 
edema,  are  more  deeply  infiltrated  and  much  more  painful. 

The  classic  treatment  of  the  trichophytic  folliculitides,  no  matter 
where  the  lesions  are  situated,  consists  of  the  careful  epilation  of 
the  patch  and  of  a  peripheral  zone  of  about  1  cm.  in  width;  as 
the  hairs  are  not  brittle,  radiotherapy  may  be  replaced  by  avulsion 
with  the  forceps,  followed  by  the  application  of  emollient  or  anti- 
septic dressings.  It  is  sometimes  necessary  to  open  the  deeper  fol- 
licular abscesses  with  the  thermocautery.  Finally,  the  affected 
surfaces  are  freely  painted  with  tincture  of  iodin  every  other  day, 
or  they  may  be  dressed  with  iodin  in  vaseline. 

However,  all  dermatologists  have  noted  that  very  freely  suppurat- 
ing trichophytoses  heal  spontaneously,  as  it  were;  thorough  epila- 
tion, cleansing  and  moist  dressings  or  starch  poultices  are  sufficient. 
This  fact  is  explained  either  by  an  immunization  or  more  probably 


SEBORRHEA  383 

by  the  expulsion  of  the  parasites  through  the  suppurative  reaction 
induced  by  them. 

The  precautionary  measures  necessitated  by  the  contagiosity  of 
this  affection  must,  of  course,  be  insisted  upon. 

SEBORRHEA. 

The  word  seborrhea,  which  means  a  flow  of  sebum,  was  introduced 
in  1840  by  Fuchs  to  designate  the  condition  named  acne  sebacea, 
by  Biett;  sebaceous  flux,  by  Rayer  and  steatorrhea  by  E.  Wilson. 

I  have  stated  above  that,  in  my  opinion,  seborrhea  is  one  of  the 
principal  manifestations  of  a  more  general  diseased  condition  which 
I  have  named  kerosis. 

The  meaning  of  the  term  seborrhea  has  been  unreasonably 
extended  by  authors  to  the  point  of  applying  it  to  all  the  other 
manifestations  of  kerosis,  and  even,  by  Hebra,  to  pityriasis  simplex, 
thereby  leading  to  the  enormous  confusion  which  still  prevails  as 
illustrated  by  the  commonly  used  but  highly  improper  terms  of 
seborrhea  sicca  (for  pityriasis  simplex),  seborrheic  eczema  (for  eczema- 
tide)  and  so  forth. 

Seborrhea  is  an  exaggerated  sebaceous  secretion.  A  distinction 
can  be  made  between  fatty  seborrhea  and  oily  or  fluid  seborrhea; 
but  there  are  numerous  intermediate  conditions. 

Fatty  seborrhea  [seborrhoea  steatosa]  is  characterized  by  the  dila- 
tation of  the  pore  and  the  "collar"  of  the  follicles,  especially  those 
with  which  the  larger  sebaceous  glands  are  connected,  with  accu- 
mulation in  the  osteo-follicular  canal  of  a  substance  composed  of 
horny  cells,  fat  and  microbes,  namely  the  sebum. 

Sometimes  the  horny  cells  predominate  and  are  concentrically 
arranged,  forming  the  seborrheic  utriculus  or  seborrheic  cocoon  of 
Sabouraud;  a  somewhat  greater  amount  of  hyperkeratosis  results, 
in  the  comedo  of  acne. 

In  other  cases,  the  fat  forms  with  the  horny  cells  a  pasty  whitish 
substance,  of  a  butyric  acid  odor,  which  can  be  expressed  by  squeez- 
ing between  two  fingernails,  under  the  aspect  of  a  worm  or  vermi- 
celli; this  is  the  seborrheic  filament. 

In  order  to  make  sure  that  the  condition  is  really  one  of  seborrhea, 
instead  of  a  dry  follicular  keratosis,  for  example,  it  is  therefore 
necessary  to  demonstrate  that  the  fatty  material  under  considera- 
tion can  actually  be  pressed  out  from  the  dilated  follicular  orifices. 
This  may  be  done  either  by  compressing  the  skin  between  the  nails, 
as  mentioned  above,  or  by  scraping  it  forcibly  with  a  glass  slide  or 
a  blunt  scalpel.  The  substance  thus  obtained  must  be  fatty; 
the  cocoons  or  filaments  are  easily  crushed.  Under  the  micro- 
scope are  seen  fat  drops  and  horny  cells  or  debris  of  horny  cells; 


384  FOLLICU LOSES 

moreover,  on  staining  the  specimen  with  an  aniline  dye,  preferably 
with  thionin,  an  enormous  number  of  microbes  become  visible. 

( Jredit  is  due  to  Sabouraud  for  having  shown  that  these  microbes, 
myriads  of  which  exist  in  the  product  of  fatty  seborrhea,  belong  to 
a  single  species  the  microbadllus  of  seborrhea.  This  is  very  small, 
barrel-  or  rod-shaped,  often  curved,  and  not  easily  grown  in  cul- 
tures. Halle  and  Civatte  have  demonstrated  in  my  laboratory 
that  it  grows  much  more  readily  and  abundantly  in  anaerobic 
cultures.  This  bacillus  was  seen  by  Unna  and  Hodara,  who  inter- 
preted it  as  the  microbe  of  acne. 

According  to  Sabouraud,  its  extreme  abundance  in  pure  cultures 
indicates  its  pathogenic  nature,  so  that  seborrhea  should  be  inter- 
preted as  a  parasitic  disease.  This  theory  is  not  acceptable,  and 
it  is  more  likely  that  this  very  widespread  microbacillus  becomes 
implanted  whenever  it  can  live  and  that  its  growth  is  secondary 
to  the  seborrhea. 

Seborrhea  oleosa  [orfluxus  sebctceus]  manifests  itself,  in  its  milder 
degrees,  by  a  greasy  and  shining  state  of  the  skin,  which  leaves  fat 
spots  on  paper;  in  the  advanced  degrees,  actual  drops  of  oil  are 
seen  to  dot  the  integument.  It  almost  invariably  coexists  with 
fatty  seborrhea.  It  is  very  difficult  to  decide  if  the  fluid  fat  is 
really  derived  from  the  sebaceous  glands  instead  of  from  the 
sweat  glands;  namely,  if  the  condition  is  not  one  of  hyperidrosis 
oleosa. 

The  usual  distribution  of  fatty  seborrhea  is  less  extensive  than 
that  attributed  to  it  by  those  writers  who  confuse  it  with  kerosis. 
Its  seat  of  election  is  in  the  center  of  the  face,  on  the  ala?  of  the 
nose  and  in  the  nasogenial  grooves;  it  is  less  common  in  the  other 
regions  of  the  face  and  on  the  vertex,  rather  rare  on  the  thorax  and 
the  genitals,  exceptional  in  other  kerotic  regions.  Oily  seborrhea 
is  observed  on  the  face,  on  the  hairy  scalp  and  sometimes  on  the 
thorax. 

Its  etiology  merges  with  the  etiology  of  kerosis.  It  is  practically 
never  observed  before  puberty.  Its  relations  with  sexual  develop- 
ment, genital  disturbances  and  gastric  affections  are  very  evident. 

The  treatment  is  also  that  of  kerosis.  Locally,  less  reliance  should 
be  placed  on  fat-removing  washes  and  lotions,  containing  ether  or 
other  ingredients,  than  on  sulphur  or  camphor,  etc.  Systematic 
massage  of  the  skin  favors  the  evacuation  of  the  retained  products; 
its  exaggerated  employment  would  be  injurious. 

THE    ACNES. 

The  term  acne  has  been  applied,  since  Willan,  to  all  eruptions 
which  were  believed  to  be  due  to  an  affection  of  the  sebaceous 


THE  ACNES  385 

glands;  the  clinical  appearance,  or  the  related  cause  or  probable 
character  of  this  affection  being  specified  by  an  adjective.  A  reac- 
tion has  set  in  against  this  linguistic  abuse  which  led  to  confusion. 

Seborrhea  is  no  longer  described  as  acne  sebacea  or  oleosa;  we  speak 
of  keratosis  senilis  instead  of  acne  sebacea  concreta;  acne  miliaris  or 
milium  is  a  form  of  epidermic  cyst;  the  acne  varioliformis  of  Bazin, 
or  molluscum  contagiosum,  is  an  epithelial  tumor;  acne  rosacea 
belongs  to  the  chronic  erythemas  and  its  complication ;  acne  hyper- 
trophica  to  the  hypertrophic  dermatoses;  acne  cornea  is  a  keratotic 
folliculitis;  acne,  decalvans  is  a  decalvating  folliculitis;  acne  cachec- 
ticorum  is  a  variety  of  tuberculide  as  acne  syphilitica  is  a  form  of 
syphilide. 

There  remains  a  dermatosis  which  is  typical  of  the  genuine  acnes, 
namely  acne  vulgaris  or  juvenilis;  and,  in  addition,  a  few  related 
varieties. 

Acne  Vulgaris  or  Juvenilis. — This  is  a  very  frequent  complica- 
tion of  kerosis  and  of  seborrhea  in  particular,  manifesting  itself 
as  a  regional,  successive,  follicular  eruption,  especially  affecting 
youthful  individuals. 

Acne  is  not  characterized  by  a  single  eruptive  lesion,  but  by  a 
polymorphous  set  of  lesions  more  or  less  derived  from  each  other; 
comedones,  papulo-pustules,  superficial  or  deep  follicular  pustules, 
indurated  abscesses,  crusts  and  cicatrices.  Besides  the  cases  with 
perfectly  developed  lesions,  there  are  very  numerous  individuals 
suffering  from  incomplete  acne,  with  a  few  comedones  and,  from 
time  to  time,  a  papulo-pustule. 

A  comedo  is  a  small  horny  mass,  with  a  brown  or  black  top,  the 
size  of  a  pinhead  to  that  of  a  millet-seed,  imbedded  in  a  dilated 
follicular  orifice  where  it  resembles  a  powder  grain.  It  can  be 
squeezed  out  by  pressure  between  two  finger-nails,  in  the  form  of 
a  firm  yellowish  mass  with  a  black  head,  followed  by  a  white 
unctuous  filament,  resembling  vermicelli  or  a  black-headed  worm. 
Sometimes,  "double  comedones"  are  encountered,  meaning  come- 
dones situated  very  close  together,  with  a  communicating  base. 

The  comedo  results  from  an  ostiofollicular  hyperkeratosis;  its 
configuration  is  that  of  a  small  cylinder  formed  by  concentric  horny 
lamellae ;  its  exposed  surface  is  colored,  not  by  a  deposit  of  dust,  but 
through  oxidation  of  the  keratin  itself;  the  cavity  from  which  it 
may  be  expressed  contains  microbacilli  in  large  numbers  and  sebum . 
It  resists  more  or  less  the  escape  of  the  sebum,  which  is  retained 
below;  in  the  face,  the  demodex  folliculorumis  not  infrequently  met 
with. 

Comedones  in  variable  number,  at  first  imperfectly  formed  and 
hardly  distinguishable  from  seborrheic  cocoons,  later  more  volum- 
inous, occur  preferably  in  the  face,  especially  on  the  nose,  the 
25 


386  FOLLICULOSES 

cheeks  and  the  temples,  on  the  chin,  the  back,  the  chest  and  the 
shoulders  and  rarely  elsewhere. 

When  they  exist  alone  they  constitute  acne  punctata,  the  "  black- 
heads" of  the  vernacular. 

A  little  redness  and  tumefaction  around  some  comedones  are 
characteristic  of  papular  acne.  The  inflammation  is  almost  invari- 
ably more  intense;  the  red  acuminate  elevation,  the  size  of  a  pin- 
head  to  that  of  a  pea,  whitens  at  its  apex  in  two  or  three  days,  due 
to  suppuration,  the  pus  may  be  evacuated  or  dry  up  as  a  crust 
while  the  papule  collapses,  becoming  transformed  into  a  brownish- 
red  spot  which  leaves  a  minute  cicatrix.  This  constitutes  super- 
ficial pustular  acne.  It  is  more  or  less  discrete  or  confluent  and 
occupies  the  face,  the  shoulders  and  the  thorax. 

The  pustules  develop  practically  without  pain  and  with  hardly  a 
little  itching. 

When  the  papulopustules  have  the  size  of  a  large  pea  or  a  bean 
and  are  hard,  purplish  and  painful,  suppuration  being  slow  but 
deep  and  abundant,  the  condition  is  described  as  an  acne  tuberosa 
or  indurata.  In  the  form  known  as  phlegmonous  acne,  the  dusky 
red  and  fluctuating  elevations  surmount  real  acneiform  abscesses, 
dermic  or  hypodermic;  sometimes  there  are  cavities  with  oily 
contents. 

These  different  varieties  are  often  associated  in  the  same  patient 
{polymorphous  acne)  in  variable  proportion  (Fig.  122).  In  severe 
cases,  the  face,  chest  and  back  may  be  covered  with  lesions  in  all 
stages  of  development  and  with  countless  cicatrices  of  variable 
size,  producing  real  deformities,  so  that  almost  no  healthy  skin  is 
left.  Sometimes  the  eruption  has  a  tendency  to  become  localized 
in  one  of  these  regions. 

The  topography  of  acne  is  very  specific;  it  practically  never 
passes  below  the  belt  line,  nor  the  upper  two-thirds  of  the  arms, 
nor  the  margin  of  the  scalp,  where  it  invariably  stops. 

The  eruption  is  maintained  through  uninterrupted  crops  of  new 
lesions;  it  is  continuous,  but  with  periods  of  exacerbation  in  the 
spring,  at  the  time  of  menstruation  or  in  connection  with  errors  in 
diet.  [It  constitutes  about  8|  per  cent,  of  all  cases  seen  in  derma- 
tological  practice  in  Ameria.] 

Etiology  and  Character. — The  condition  sine  qua  non  of  acne  is 
kerosis;  individuals  having  acne  always  suffer  from  seborrhea, 
pityriasis  simplex  and  sometimes  from  eczematides.  A  predis- 
posed soil  is  present  and  persists  beyond  the  acne. 

The  eruption  begins  in  both  sexes  at  the  approach  of  puberty, 
flourishes  toward  the  sixteenth  and  eighteenth  year  and  diminishes 
between  the  twenty-second  and  the  thirtieth  year;  it  is  not  uncom- 
monly followed  by  rosacea,  baldness  or  eczematides. 


THE  ACNES 


387 


The  causes  of  kerosis  accordingly  predispose  likewise  to  acne;  in 
the  first  place,  the  molimina,  genital  excitement,  functional  or 
organic  genital  disturbances.  A  very  correct  observation,  fre- 
quently made,  is  that  acne  localized  on  the  chin  of  young  girls 
or  young  women  almost  certainly  indicates  some  utero-ovarian 
ailment. 

Digestive  disturbances,  improper  diet,  gastric  dyspepsia  and 
habitual  constipation  play  an  equally  important  part. 

A  pale  complexion,  a  "lymphatic"  or  "arthritic"  constitution,  are 
often  met  with  in  acne  patients,  especially  those  with  a  kerotic 
heredity. 


Fig.  122. — Juvenile  polymorphous  acne. 

As  to  the  determining  cause  of  the  eruption,  that  which  trans- 
forms a  seborrhea  into  acne,  it  is  practically  certain  that  this  is 
primarily  of  local  microbic,  infectious  origin.  This  is  not  an  estab- 
lished fact  for  comedo,  although  Sabouraud  has  shown  that  the 
comedo  contains  in  its  interior  myriads  of  seborrheic  bacilli  (the 
old  acne  bacillus  of  Unna  and  Hodara),  and  that  in  its  surroundings 
the  bottle-bacillus  and  cocci  are  usually  present. 

The  acne  pustule  almost  regularly  encloses,  sometimes  in  enor- 
mous numbers,  staphylococci  of  various  kinds,  which  are  pyogenic; 
the  pustule  is  only  rarely  sterile, 


388  FOLLICULOSES 

From  the  benign  character  of  this  suppuration,  its  freedom  from 
pain,  its  slow  development,  it  may  be  inferred  that  the  ordinary 
causative  agent  is  not  a  virulent  staphylococcus,  such  as  the  Staphy- 
lococcus aureus,  but  more  probably  the  Staphylococcus  albus  or 
the  staphylococcus  growing  in  gray  cultures,  the  polymorphous 
coccus  of  Cedercreutz,  or  an  analogous  organism. 

Summarizing,  the  acne  pustule  is  a  folliculitis  and  perifolliculitis 
of  a  follicle  obstructed  by  a  comedo  and  infected  by  a  pyococcus  of 
moderate  virulence.  The  abscess,  resulting  from  the  onrush  of 
leukocytes,  is  primarily  situated  in  the  wall  of  the  follicle,  under  the 
comedo,  destroys  this  wall  in  a  part  at  least  of  its  circumference 
and  more  or  less  deeply  invades  the  perifollicular  tissue;  this  explains 
why  it  leaves  a  cicatrix.  The  sebaceous  gland  plays  only  a  very 
subordinate  part  in  the  process. 

Treatment. — Both  local  and  general  treatment  are  required. 

Locally,  the  skin  must  be  kept  very  clean  by  means  of  baths 
and  warm  soapy  or  alcoholic  lotions.  Camphorated  alcohol,  at 
first  dilute,  camphor  and  sulphur  lotions,  sulphuretted  or  mercur- 
ial washes,  or  chlorhydrate  of  ammonia,  yield  much  better  results 
than  salves  of  any  kind.  Mild  measures  must  be  employed  to 
begin  with,  for  the  skin  in  some  cases  of  acne  is  extremely  irri- 
table. 

After  washing  with  soap,  before  applying  the  selected  lotion,  it 
is  advisable  to  squeeze  out  the  comedones  from  time  to  time,  by 
systematic  massage,  pressure  with  a  watch-key,  or  even  by  means  of 
a  special  "comedo  punch"  and  to  open  the  superficial  pustules 
with  a  flamed  needle.  These  procedures  must  not  be  overdone, 
however,  as  the  eruption  is  occasionally  aggravated  in  this  way. 

In  severe  and  obstinate  cases,  the  rapid  exfoliating  method  is 
recommended;  I  have  repeatedly  been  enabled  to  obtain  nearly 
complete  and  durable  cures  with  it.  Gradual  exfoliation  is  often 
equally  successful,  for  example  with  the  "strong  salve"  of  Brocq 
(see  Therapeutic  Notes)  which  is  allowed  to  act  from  five  to  thirty 
minutes  before  a  lukewarm  wash  or  bath.  The  irritation  is  then 
soothed  by  means  of  a  zinc  paste. 

In  case  of  indurated  or  phlegmonous  acne,  the  galvanocautery, 
if  necessary  the  thermocautery,  serve  to  evacuate  the  purulent 
collections  and  suppress  the  developing  lesions.  Radiotherapy, 
employed  as  a  last  resort,  sometimes  yields  very  valuable  results. 

The  internal  treatment  must  aim  in  the  first  place  at  the  correction 
of  the  general  hygiene.  The  diet  must  be  closely  regulated,  omit- 
ting all  stimulants,  sweets  of  all  kinds,  fermentable  substances  and 
an  excess  of  meat.  The  physician  must  see  to  the  regularity  of 
meal  hours,  good  mastication,  the  condition  of  the  teeth,  regular 
evacuation  of  the  bowels,  which  will  sometimes  have  to  be  secured 


THE  ACNES  389 

by  suitable  laxatives.  Disturbances  of  the  genitourinary  appara- 
tus must  be  corrected  as  far  as  possible.  Exercise,  friction  of  the 
cutaneous  surface  and  massage  contribute  to  regulate  the  general 
circulation. 

L.  Jacquet  advocated,  besides  bradyphagia,  "massage  of  the 
face  by  petrissage"  and  facial  gymnastics;  these  measures  often 
prove  really  efficient. 

The  remedies  to  be  recommended  are,  according  to  the  cases  and 
sometimes  successively,  arsenic,  cod-liver  oil,  ferruginous  agents, 
ichthyol,  beer-yeast  and  lactic  ferments;  the  latter  are  sometimes 
highly  successful,  sometimes  entirely  inefficient.  Staphylococcic 
vaccintherapy,  or  better,  inoculation  with  a  mixed  autovaccine,  may 
likewise  have  excellent  results  or  in  other  cases  prove  useless. 

[In  my  experience,  juvenile  acne  may  be  successfully  treated  by 
local  measures  alone  without  any  regard  to  the  general  health. 
Proper  exercise,  regular  bowel  movements  and  a  diet  free  from 
excesses  of  all  kinds  are  good  for  every  one  but  I  have  never  been 
able  to  clearly  establish  a  relationship  between  juvenile  acne  and 
any  general  abnormalities  whatever.  One  of  the  most  severe  and 
most  obstinate  cases  of  acne  I  have  ever  encountered  occurred  in 
an  otherwise  perfect  specimen  of  young  manhood  who  lived  at  the 
trainer's  table  and  observed  the  severe  regimen  required  of  a  mem- 
ber of  a  college  athletic  team. 

My  plan  of  treatment  consists  of  various  measures  of  local  anti- 
septics: washing  with  soap,  avoidance  of  friction  with  the  towel 
which  serves  to  spread  infection,  soaking  ten  to  fifteen  minutes 
with  a  1  to  2000  weak  alcoholic  watery  solution  of  bichloride  of 
mercury  (the  soap  must  be  thoroughly  rinsed  off  first)  and,  after 
washing  away  the  bichloride  solution  and  drying,  an  application  of 
sulphur  paste,  i.  e.,  zinc  oxide  ointment  containing  10  per  cent,  of 
kaolin  and  10  per  cent,  of  precipitated  sulphur,  to  be  applied  at 
bed-time.  In  the  morning  a  soap  and  water  wash.  The  kerato- 
lytic  action  of  the  paste  becomes  obvious  after  five  to  ten  days;  the 
skin  feels  tight,  drawn,  as  if  coated  with  varnish.  This  symptom 
is  the  signal  for  omitting  the  sulphur  paste  one  night  and  applying 
instead  a  soothing  and  softening  cream  consisting  of  2  per  cent, 
salicylic  acid  in  cold-cream  or  petrolatum.  The  next  night  the 
paste  may  be  resumed  and  thereafter  must  be  interrupted  by  one 
night  of  the  cream  every  fourth  or  fifth  day.  At  the  same  time 
it  is  of  primary  importance  to  remove  mechanically  as  many  sources 
of  infection  as  possible;  comedones  must  be  squeezed  out  and 
pustules  evacuated  systematically  at  intervals  of  three,  later  seven 
to  ten  days.  My  own  experience  with  vaccines  has  not  been 
favorable;  others,  notably  Gilchrist  and  Engman  have  reported 
excellent  results.! 


I'.MI 


FOLLICULOSES 


Medicinal  and  Occupational  Acnes.  -These  are  closely  related  to 
juvenile  acne  and  if  proof  were  required,  would  show  the  part 
played  by  the  ingesta  as  well  as  1»\  external  irritants  in  the  genesis 
of  this  skin  disease. 

The  iodides  and,  to  a  less  degree,  the  bromides  produce  in  some 
individuals,  either  from  the  start  or  after  prolonged  administration, 
an  iodide  or  bromide  acne;  it-  special  features  are  the  age  of  the 
patient-,  the  sudden  onset  and  the  inflammatory  indurated  nodu- 
lar character  of  the  eruptive  lesions.  These  acnes  are  localized 
chiefly  on  the  face  and  the  hack  and  may  become  associated  with 
other  symptoms  of  iodism  or  bromism. 


Fig.   123. — Cade  oil  acne;  internal  aspect  of  the  right  thigh  in  a  case  of  psoriasis 
treated  with  an  nil  of  cade  glycerolate.     The  pustules  contained  the  Staphylococcus 

aureus;  cured  by  means  of  a  soapy  salve. 


The  various  preparations  of  tar.  oil  of  cade  in  particular,  give 
rise  in  those  who  handle  them  or  apply  them  to  the  -kin  (in  the 
treatment  of  psoriasis,  for  example i  to  an  eruption  of  reddish- 
brown  papulopustules,  centered  by  a  comedo,  very  much  like  acne 
(Fig.  1-':;). 

Mineral  oil-,  employed  for  the  lubrication  of  engines,  may  cause 
either  acute  suppurative  folliculitides  or  subacute  acneiform  fol- 
liculitides,  analogous  to  tar  acne.  All  these  hydrocarbons  act 
apparently  by  producing  an  ostio-follicular  hyperkeratosis,  which 
retains  the  pyococci  and  creates  conditions  favorable  to  their  growth 
and  to  an  inflammatory  reaction  of  the  integument. 

Chlorin  acne  presents  the  features  of  juvenile  acne,  although 
greatly  exaggerated,  with  an  extraordinary  profusion  of  comedones 
and  a  general  distribution  over  regions  which  escape  in  common 


The  acnes  39 i 

acne;  it  has  been  observed  in  laborers  employed  in  sodium  chloride 
electrolytic  works.  According  to  Fumouze  (1901)  it  is  due  to 
nascent  sodium  hypochlorite. 

Acne  Necrotica  of  Boeck  (Acne  Pilaris  of  Bazin,  Acne  Varioli- 
formis of  Hebra,  Frontalis,  Rodens,  etc.) . — This  is  a  disease  affecting 
middle-aged  and  old  persons  and  presents  characteristic  lesions. 

The  eruption  consists  of  pink  or  waxy  papules  the  size  of  a  pin- 
head  to  that  of  a  small  lentil,  whose  apex  very  rapidly  assumes  a 
yellowish  hue,  simulating  a  vesico-pustule  and  dries  to  a  biconvex 
brownish-yellow  crust;  this  very  adherent  crust  is  embedded  in 
the  skin  and  encircled  by  a  sometimes  slightly  raised  border;  its 
fall  is  often  delayed  and  leaves  an  indelible  depressed  cicatrix. 

Advancing  in  continuous  or  intermittent  crops,  the  eruption  is 
situated  on  the  forehead,  at  the  border  of  the  scalp  which  is  often 
in  part  invaded,  at  the  temples,  in  the  conchae  of  the  ears,  some- 
times on  the  nose  and  in  the  nasogenial  grooves  and  very  rarely  on 
the  middle  of  the  back  and  the  chest.  The  lesions  are  grouped  or 
disseminated.  The  affected  regions  finally  become  riddled  with 
cicatrices.  When  left  untreated,  the  affection  lasts  for  years  and 
even  indefinitely. 

The  histological  lesion  consists  of  a  dry  lenticular  necrosis,  situ- 
ated at  the  orifice  of  a  follicle  and  comprising  the  entire  thickness 
of  the  epidermis  and  a  superficial  portion  of  the  cutis;  surrounded 
by  an  inflammatory  zone  with  thrombosis  of  the  bloodvessels. 

Necrotic  acne  is  distinguished  from  crusted  secondary  syphilides 
by  its  necrotic  character  and  its  cicatrices;  from  tuberculo-crusted 
tertiary  syphilides,  by  the  absence  of  induration  and  by  the  dis- 
semination of  the  lesions. 

Only  the  microbacillus  of  seborrhea  and  various  staphylococci, 
especially  the  aureus,  have  ever  been  discovered  in  this  acne;  it 
is  probable  that  another  etiological  factor  is  involved,  but  it  is 
unknown.     Kerosis  and  seborrhea  constitute  the  necessary  soil. 

Appropriate  treatment  ensures  a  cure  in  a  few  days.  The 
employment  of  soap  and  water  and  of  a  strong  sulphur-cade-  and 
salicylic-acid  salve  is  sufficient;  all  internal  medication  is  unneces- 
sary. Sulphur  washes  or  a  sulphur  salve  are  recommended  for 
the  prevention  of  recurrences.  [I  have  found  soap  and  water  and 
the  application  of  ammoniated  mercury  ointment,  which  is  not 
unpleasant,  quite  sufficient  for  a  cure.] 

Keloid  Acne. — This  affection,  first  described  by  Bazin — identical 
with  the  dermatitis  papillaris  capillitii  of  Kaposi — occurs  essentially 
in  males  and  is  almost  exclusively  observed  at  the  nape  of  the  neck, 
at  the  border  of  the  hairy  scalp  and  very  rarely  in  the  beard. 

It  begins  as  an  acuminated  papular  folliculitis,  the  size  of  a  millet 
or  hemp  seed,  which  may  become  pustular;  originally  disseminated, 


392  FOLLICULOSES 

the  lesions  multiply  and  become  grouped,  finally  coalescing  into  a 
band  which  occupies  the  entire  posterior  border  of  the  scalp. 

This  folliculitis  is  distinguished  from  the  start  by  its  subacute 
infla.TTiTnfl.tnry  character,  its  very  marked  induration  and  a  course 
Leading  to  the  formation  of  fibrous  excrescences. 

The  confluence  of  these  lesions  results  in  a  horizontal  row  of 
agglomerated  fibrous  tubercles  and  finally  a  "cushion"  which  may 
have  the  thickness  of  a  finger,  a  length  of  10  to  15  cm.,  or  even 
extend  from  one  ear  to  the  other.  Cicatricial  and  smooth  on  its 
lower  aspect,  this  cushion  bristles  on  its  upper  side  with  hairs 
arranged  in  tufts  or  wisps.  On  pulling  these  out,  one  is  surprised 
by  the  depth  of  their  implantation. 

The  duration  of  the  affection  is  indefinite;  it  may  be  prolonged  for 
fifteen  to  twenty  years,  or  longer.  The  cushion  slowly  extends 
upward  on  the  occipital  region,  never  in  a  downward  direction,  and 
leaves  behind  it  a  pinkish,  more  or  less  thickened  permanent  cicatrix. 

Histology  shows  a  chronic  follicular  inflammation,  noteworthy 
in  that  the  cellular  infiltration  is  almost  exclusively  composed  of 
plasmocytes,  with  a  few  giant  cells;  it  leads  to  the  formation  of  a 
dense  hyperplastic  fibrous  tissue;  the  process  is  absolutely  different 
from  that  of  the  true  keloids,  as  shown  especially  by  Pautrier  and 
J.  Gouin.  Its  nature  is  not  known  and  the  special  microbic  agent 
which  is  probably  present  has  not  been  demonstrated.  The  co- 
existence of  kerosis  is  invariable. 

Keloid  acne  is  very  obstinate  to  treatment.  Antiseptic  washes, 
iodin  applications,  mercurial  ointments,  sulphur,  naphthol  and  tar 
salves  are  indicated  only  in  the  first  stage  and  are  rarely  sufficient. 
The  best  obtainable  results  are  secured  by  the  following  method: 
First,  all  the  active  lesions  of  folliculitis  are  destroyed  with  a  fine- 
pointed  thermocautery;  then  the  keloid  growths  are  attacked  by 
very  deep  and  repeated  scarifications,  followed  eight  or  ten  days 
later  by  a  number  of  radiotherapeutic  sessions. 

In  well-marked  cases,  surgical  removal  is  advantageously  per- 
formed, followed  by  radiotherapy.  Extirpation  alone  is  not  to  be 
recommended  as  it  is  often  followed  by  recurrence. 

CICATRICIAL  DEPILATING   FOLLICULITIDES. 

The  nosographical  group  of  depilating  folliculitides,  or  acne 
decalvans,  is  indefinitely  outlined  and  its  varieties  are  still  imper- 
fectly formulated  for  lack  of  knowledge  of  the  etiological  factors. 
All  the  dec])  folliculitides  may  become  depilatory  through  perma- 
nent atrophy  of  the  follicle,  as  in  furuncle,  favus,  keratosis  pilaris, 
sycosis,  the  acnes  and  the  syphilides.  But  those  under  present 
consideration   arc   inflammatory,   sluggish,   progressive,   rebellious, 


CICATRICIAL  DEPILATING  FOLLICU  LI  TIDES 


393 


often  agminated  and  necessarily  leave  true  cicatricial  tissue  behind 
them;  they  are  the  forms  which  lead  to  the  cicatricial  alopecias. 

Pseudo-pelade  of  Brocq  {alopecia  atrophicans  of  foreign  authors) 
represents  the  most  typical  form.  It  is  characterized  by  alopecic 
and  cicatricial  spots  or  patches,  scattered  or  grouped  on  an  other- 
wise healthy  scalp.  These  spots  have  various  dimensions  and 
shapes,  being  sometimes  barely  lenticular,  rounded  and  very 
numerous;  sometimes  several  centimeters  in  diameter,  irregular, 
with  geographical  outlines;  or  the  two  varieties  may  be  associated 
(Fig.  124).  The  borders  are  distinct,  without  a  transitional  zone; 
the  surface  is  wax-white  or  faintly  pink,  perfectly  smooth,  without 
scales  or  broken  or  lanugo  hairs;  even  the  follicles  have  disappeared, 
as  may  be  ascertained  by  painting  the  surface  with  tincture  of 
iodin. 


wF  & 

W    m  • 

nj        Ik 

H 

-J 

L   •• 

Fig.  124. — Pseudo-pelade  of  Brocq. 

This  affection  is  met  with  on  the  hairy  scalp  of  youthful  or  adult 
individuals,  especially  in  men  and  rarely  in  the  beard.  The  medium- 
sized  and  large  spots  are  evidently  the  result  of  growth  and  con- 
fluence of  small  spots.  The  onset  is  insidious  and  usually  escapes 
notice;  Dreuw  believes  that  it  takes  place  in  childhood  as  an  alopecia 
parvimaculata. 

In  watching  the  progress  of  the  affection,  which  is  extremely 
slow,  it  is  seen  to  begin  with  a  slight  orificial  keratosis  at  one  or 
several  hairs  surrounded  by  a  pinkish  area,  at  the  border  of  the 
patch;  next  follows  the  definite  loss  of  these  hairs  and  the  extension 


394  FOLLICULOSES 

of  the  cicatrix  to  this  area.  Despite  all  efforts  and  despite  the  prob- 
ability of  a  parasitic  cause  no  special  fungus  or  microbe  has  ever 
been  found  in  the  hairs  or  in  the  follicles.  Under  the  microscope  a 
cellular  infiltration  is  seen  around  the  follicles  and  around  the  blood- 
vessels and  lymph  vessels  which  are  greatly  dilated;  the  process 
terminates  in  a  connective-tissue  and  elastic  atrophy.  It  is  certain 
that  pseudo-pelade  must  be  considered  as  a  folliculitis,  but  it  will  be 
noted  that  the  follicular  inflammation  is  clinically  not  very  evident, 
far  less  so  than  in  the  following  forms. 

The  differences  between  pseudo-pelade  and  ringworm  are  con- 
siderable. There  is  a  much  greater  analogy  with  the  cicatrices  of 
favus,  so  much  so  that  in  my  opinion  the  disease  would  be  better 
designated  pseudo-favic  alopecia,  but  there  have  never  been  yellow 
pits  or  scutula,  the  cicatricial  skin  is  not  so  red,  the  hairs  are  not 
dull  and  lusterless  and  there  is  no  fungus.  The  patches  of  lupus 
erythematodes  are  less  numerous  and  the  process  extends  in  the 
form  of  very  red  and  hyperkeratotic  spots. 

By  means  of  sulphur  lotions,  sulphur,  cade,  naphthol,  resorcin 
salves,  mercurial  ointments,  etc.,  one  may  hope  to  arrest  the 
progress  of  the  disease,  but  not  to  restore  the  hairs  whose  follicles 
have  been  destroyed.  The  treatment  should  therefore  begin  as 
early  as  possible. 

Folliculitis  Decalvans. — Folliculite  epilante  of  Quinquaud — acne 
decahans  of  Lallier — is  perhaps  merely  a  variety  of  the  preceding 
type  from  which  it  differs  only  by  the  presence  in  the  invaded  zone 
of  a  few  scattered  pustular  follicles,  the  size  of  a  pinhead  or  a  small 
pea. 

Lupoid  Sycosis  of  Brocq. — Lupoid  acne  of  American  writers, 
ulerythema  sycosiforme  of  Unna,  dermatitis  sycosiformis  atrophicans 
of  Ducrey  and  Stanziale,  is  situated  on  the  beard  and  especially  on 
the  cheeks  (Fig.  125).  It  gives  rise  to  agrainated  follicular  pustules, 
with  inflammatory  redness  and  diffuse  superficial  infiltration  of  the 
skin. 

It  differs  from  ordinary  sycosis  by  its  tendency  to  extend  uni- 
formly and  by  the  red,  smooth,  central  cicatricial  alopecia,  often 
of  a  keloidal  appearance,  which  it  leaves  behind.  It  may  greatly 
resemble  a  flat  lupus  vulgaris  in  course  of  central  cicatrization; 
but  there  are  no  lupomas  and  only  suppurative  folliculitis.  The 
single  focus,  or  at  most  two  or  three  foci,  in  the  course  of  years  may 
attain  the  dimensions  of  the  palm  of  the  hand. 

Depilating  follicvlitides  of  the  smooth  parts,  described  by  Arnozan 
and  Dubreuilh,  which  occupy  the  thighs  and  legs,  are  still  more 
rare;  they  constitute  a  type  related  to  the  above  or  perhaps  a  form 
of  tuberculides. 

Furthermore,  an  entire  series  of  cases  of  necrotic  (Janovky)  or 


SUB  A  C  V  TE  FOLLIC  VLI TI DES 


395 


ulcerative  (Bizzozero)  jolliculitid.es  or  perifolliculitides  has  been 
reported;  their  significance  and  nosological  position  have  not  been 
determined. 

Treatment. — Washes  with  alcohol  or  sublimate,  yellow  oxide 
salves  and  mercurial  plasters,  combined  with  epilation,  have  long 
been  the  best  means  for  combating  the  progress  of  lupoid  sycosis 
and  analogous  affections.  Radiotherapy  is  greatly  superior  to 
these  measures  and  vields  note  worth  v  results. 


Fig.  125. — Lupoid  sycosis. 


SUBACUTE    FOLLICULITIDES. 

There  exists  a  group  of  red  folliculitides,  of  acute  or  rather  sub- 
acute course,  which  are  neither  regularly  suppurative  nor  necessarily 
depilatory. 

Follicular  Eczematides. — I  employ  this  term  for  the  peripilar 
seborrheids  of  authors.  The  acute  form  manifests  itself  especially  in 
markedly  kerotic  men,  preferably  at  the  beginning  of  the  warm 
weather,  in  the  form  of  an  eruption  of  small  red  acuminate  follic- 
ular papules,  agminated  in  one  or  several  patches  on  the  back,  the 
shoulders  or  the  anterior  side  of  the  trunk.  The  patch  extends  by 
invasion  of  all  the  neighboring  follicles,  while  at  the  center  the 
eruption  subsides  and  leaves  behind  a  yellow  slightly  desquamating 
surface.  The  course  is  rapid  at  the  onset.  The  diseased  surface 
attains  the  size  of  the  hand  in  the  course  of  a  week  or  two;  later  on 
it  is  sluggish. 


396 


FOLLICULOSES 


A  subacute  form  of  this  affection  has  been  frequently  described. 
It  is  characterized  by  small  spots  of  a  yellowish  red,  or  a  purplish 
red,  perifollicular,  barely  papular,  arranged  in  groups  of  ten  to 
thirty,  which  gradually  become  more  prominent  and  covered  with 
a  yellowish  scale  or  crust  (Fig.  126).  Continence  of  these  lesions 
may  lead  to  the  production  of  spots  of  figured  eczematides. 

Their  scat  of  election  is,  moreover,  the  same  as  that  of  the  figured 
eczematides  which  may  have  preceded  the  follicular  eruption.  The 
latter  is  frequently  seen  also  on  the  limbs,  the  thighs,  the  legs,  the 
wrists,  the  forearms,  etc.     Pruritus  is  very  slight. 


Treatment  with  sulphur  baths,  sulphur  or  ichthyol  salves,  is  very 
promptly  effective  in  the  acute  form;  it  must  be  more  energetic  or 
more  prolonged  in  the  sluggish  varieties. 

Eczema  Folliculorum  of  Malcolm  Morris  and  Unna  is,  I  believe, 
merely  a  rare  variety  of  the  preceding  affection.  It  consists  of  a 
non-suppurative  folliculitis,  agminated  in  small  red  patches,  which 
are  distributed  on  the  trunk  and  especially  on  the  limbs,  progres- 
sing extensively,  with  a  tendency  to  complete  eczematization. 
Pruritus  is  sometimes  rather  troublesome  and  causes  scratching. 
This  form  is  somewhat  rebellions  to  treatment. 

Follicular  Syphilides.  Among  the  papular  secondary  syphilides, 
there  is  a  form  with  small  papules,  known  as  miliary,  granular, 
lichenoid,  or  acneiform  peripilar  syphilides.  They  result  from  a 
localization  of  the  syphilitic  infiltration  around  and  beneath  the  pilo- 


SUBACUTE  FOLLICU  LI  TIDES 


397 


sebaceous  follicles;  it  usually  seems  to  be  invited  by  a  preliminary 
lesion  of  these  follicles,  in  the  form  of  kerosis  or  of  keratosis  pilaris. 
The  follicular  syphilides  usually  make  their  appearance  from  four 
to  eighteen  months  after  the  chancre;  this  is  therefore  a  secondary 
manifestation  but  not  one  of  the  earliest.  A  distinction  is  made 
between  a  papulo-squamous,  papulo-pustular  and  even  a  vesicular 


Fig.  127, 


-Follicular  syphilides,  papulo-squamous  variety.  On  the  face  the  eruption 
was  distinctly  papulo-lenticular. 


variety.  The  eruption  is  disseminated  but  very  often  consists  of 
small  groups  of  agminated  lesions  (Fig.  127).  Its  seat  of  election  is 
on  the  trunk,  where  it  is  seen  on  the  back,  flanks  and  loins;  the 
limbs  may  also  be  involved. 

The  papulo-squamous  variety  consists  of  small  miliary  elevations, 
of  a  dusky  red  color,  acuminate  and   crowned  with  a  dry  scale 


398  FOLLICULOSES 

which  is  enclosed  in  the  follicular  orifice  and  not  easily  removed. 
The  principal  features  of  these  lesions  are  their  firmness,  so  that 
they  feel  like  granules  to  the  finger  and  their  relatively  slow  devel- 
opment; they  persist  several  weeks  without  change. 

The  papuh-pustular  variety  may  become  combined  with  the 
preceding  in  the  same  eruption,  or  it  may  exist  alone;  it  is  often 
very  diffuse  and  abundant.  The  dark-red  perifollicular  protuber- 
ance is  larger  than  in  the  squamous  variety,  even  lenticular  in  size; 
it  is  surmounted  by  a  vesico-pustule,  always  containing  much  less 
fluid  than  one  would  expect,  rapidly  drying  into  a  crust.  Under 
the  vesicle  or  the  crust  is  seen  a  dilated,  sometimes  eroded  follicular 
orifice. 

According  to  the  size  and  appearance  of  the  papulo-pustules  or 
papulo-vesicles,  the  terms  of  acneiform,  varicelliform,  herpetiform, 
varioliform  syphilides  have  been  employed  (A.  Fournier).  There 
occur  transitional  cases  between  this  variety  and  the  papulo-crusted 
or  ulcerative  syphilides. 

Whether  squamous  or  pustular,  these  syphilides  may  in  some 
cases  become  arranged  in  rings,  or  grouped  in  collections  of  about 
fifteen  to  at  most  fifty  lesions,  sometimes  around  a  large  lenticular 
or  crusted  papule.  These  agminated  efflorescences,  absolutely  char- 
acteristic of  syphilis,  have  been  picturesquely  described  as  syphilides 
en  bouquets  and  corymbiform  syphilides. 

Careful  study  of  the  features  of  the  eruption  and  the  concomitant 
symptoms  will  guard  against  confusion  of  follicular  syphilides  with 
keratosis  pilaris,  follicular  eczematides,  pityriasis  rubra  pilaris,  or 
with  acne,  papulo-necrotic  tuberculides,  etc.  The  differential  diag- 
nosis from  lichen  scrofulosorum  may  be  much  more  difficult  even 
with  the  help  of  a  biopsy,  for  their  structure  is  rather  commonly 
tuberculoid,  but  there  is  a  positive  Wassermann  reaction. 

The  follicular  syphilides  are  tenacious,  rebellious  to  treatment, 
often  leave  persistent  brownish  macules,  and  have  a  tendency  to 
recurrence.  Treated  with  mercury,  they  last  six  weeks  or  longer;  by 
means  of  arsenobenzol  they  can  be  removed  in  two  or  three  weeks. 

Follicular  Tuberculides. — I  have  previously  discussed  the  lich- 
enoid tuberculides  with  small  acuminate  and  peripilar  lesions,  which 
belong  under  the  heading  of  lichen  scrofulosorum. 

The  papulo-necrotic  tuberculides  seem  to  be  so  evidently  related 
to  the  follicles  that  their  first  description  by  Barthelemy  was  given 
under  the  names  of  folliclis  and  aortitis.  Histological  examination 
serves  to  confirm  the  clinical  impression  in  this  respect.  It  would, 
therefore,  be  justifiable  to  group  them  among  the  folliculoses;  at 
any  rate,  the  question  of  their  differential  diagnosis  from  follicular 
affections  is  constantly  raised.  Their  follicular  localization  is  really 
accidental,  however;  it  is  sufficient  proof  to  point  out  that  these 


PITYRIASIS  RUBRA  PILARIS  399 

tuberculides  very  commonly  affect  the  palmar  region,  where  follicles 
are  absent.  The  reader  is  therefore  referred  to  another  chapter 
for  this  description. 

PITYRIASIS    RUBRA   PILARIS. 

Devergie,  E.  Besnier  and  Richaud  have  described  under  this 
name  a  skin  disease  distinct  from  psoriasis,  from  genuine  pityriasis 
rubra  [Hebra]  and  from  lichen  planus,  in  spite  of  a  few  real  analogies. 
On  the  other  hand,  Hebra  and  Kaposi  have  studied  under  the  name 
of  lichen  rubra  acuminatus  an  eruption  resembling  it  to  such  a 
degree  that  at  the  International  Congress,  Paris,  1889,  the  identity 
of  the  two  pathological  types  was  admitted ;  Kaposi  himself  empha- 
sized this  identity.  It  is  desirable,  however,  to  reserve  the  name 
of  lichen  acuminatus  only  for  the  acuminate  forms  of  Wilson's 
lichen,  which  are,  however,  very  rare. 

The  characteristic  lesion  of  pityriasis  rubra  pilaris  is  a  small 
squamous  follicular  papule.  It  is  of  a  bright  or  dull  red  color,  or 
pinkish,  sometimes  colorless  at  first,  prominent,  of  acuminate 
shape  with  a  conical  apex  which  bears  a  follicular  orifice  covered 
by  an  adherent,  dry,  white  scale,  enclosing  one  or  more  often 
atrophied  and  shrivelled  lanugo  hairs.  These  follicular  papules  are 
dry;  they  are  never  seen  to  be  vesicular  or  pustular;  their  size  is 
that  of  a  pin-head  or  a  millet-seed;  they  are  firm  to  the  touch  and 
as  a  result  of  their  distribution  the  skin  takes  on  a  granular  appear- 
ance and  has  the  feeling  of  a  grater  when  scrubbed  with  the  hand. 

Isolated  at  first,  these  papules  multiply  and  become  agminated 
later  on;  the  intermediate  skin  becomes  reddened  and  there  follow 
thickened  spots,  patches,  or  surfaces,  of  all  dimensions,  of  a  yellow- 
ish-pink color,  covered  with  pityriasic  or  psoriatiform,  sometimes 
granular  scales,  dotted  with  horny  points  or  quadrilated  and  lichen- 
ized.  Their  borders  are,  as  a  rule,  irregular,  dentated  and  sur- 
rounded by  characteristic  peripilar  papules  (Fig.  128). 

The  eruption  is  usually  distinctly  symmetrical.  Its  distribution 
is  fairly  constant  in  fully  developed  cases  and  presents  itself  under 
typical  aspects  in  the  affected  regions:  the  scalp,  as  a  pityriasis 
with  abundant  white  scales;  the  hairs  do  not  fall  out;  on  the  face, 
no  pilary  cones  are  seen,  but  a  diffuse  scaly  redness,  with  tension 
of  the  skin,  even  ectropion,  or  a  chalky  appearance,  with  greasy 
crusts  on  the  eyebrows  and  in  the  nasogenial  grooves;  on  the 
elbows  and  knees,  red  patches  are  observed  with  thick,  adherent, 
roughened  scales,  less  sharply  limited  than  those  of  psoriasis. 

The  dorsal  surface  of  the  phalanges,  even  more  than  the  last- 
named  regions  is  a  seat  of  election  of  pityriasis  pilaris;  sometimes 
red  papules  agglomerated  in  patches  are  seen;  in  other  cases  only 


400 


FOLLICULOSES 


blackish  horny  cones  at  the  pilary  orifices;  these  lesions  are  almost 
pathognomonic.     The  nails  are  striated. 

The  palmar  and  plantar  regions  are  of  a  dusky  red  color;  their 
horny  layer  is  thickened,  dry,  fissured  at  the  folds,  sometimes  des- 
quamating; the  transition  into  healthy  skin  is  gradual,  imperceptible. 

The  limbs  and  often  also  the  trunk,  are  the  seat  of  more  or  less 
grouped,  acuminate  papules  and  patches  or  thick  and  scaly  sur- 
faces, which  may  cover  large  stretches,  almost  the  entire  body, 
although  a  few  localities  at  least  are  always  exempt.  The  healthy 
-pairs  are  angular  and  limited  by  concave  curves. 


Fig.    128.    -Pityriasis  rubi 
five  years;  the  al 


Anterior  surface  of  the  thigh;  man  aged  twenty- 

•alized  eruption  dated  hack  three  years. 


The  patients  sometimes  complain  of  itching  or  heat  and  usually 
of  a  sensation  of  tension. 

The  course  of  pityriasis  rubra  pilaris  is  very  variable.  At  the 
onset,  the  palmar  and  plantar  regions,  or  the  elbows  and  knees, 
or  also  the  dorsal  aspect  of  the  phalanges  and  the  hairy  scalp  may 
be  alone  affected  for  a  period  of  months  or  years.  So-called  abor- 
tive cases  are  therefore  frequently  met  with.  Sometimes,  follicular 
papules,  grouped  on  the  limbs  or  on  the  trunk,  are  the  only  demon- 
strable symptom. 

As  a  rule,  the  more  or  les>  prolonged  periods  of  invasion  and 
confluence  arc  interrupted  by  long  stationary  stages.  Sudden 
extensions,  as  in  exfoliative  erythroderma,  are  likewise  noted. 


FOLLICULAR  KERATOSIS  401 

The  histological  lesions  consist  essentially  of  a  laminated  hyper- 
keratosis of  the  follicular  infundibulum,  composed  of  horny  plugs, 
around  a  hair  which  is  preserved  or  atrophied  or  broken  off  short. 
The  granular  layer  persists  and  is  sometimes  even  hypertrophied. 
The  rete  is  thinned  or  slightly  thickened,  sometimes  stretched. 
The  congested  papillary  body  presents  a  variable  degree  of  cellular 
infiltration,  often  rather  scanty  and  diffuse.  There  is  nothing 
to  suggest  psoriasis  or  lichen. 

The  nature  of  the  disease  is  shrouded  in  mystery.  It  is  known 
to  occur  at  any  age,  especially  during  adolescence  and  youth,  the 
male  sex  being  somewhat  more  frequently  affected,  but  its  etiology 
is  entirely  unknown. 

In  December,  1906,  Milian  suggested  a  tubercular  origin  of 
pityriasis  rubra  pilaris,  on  the  ground  of:  (1)  The  remarkable 
frequency  of  tuberculosis  among  these  patients;  (2)  the  existence 
of  intermediate  cases  between  lichen  scrofulosorum,  true  tuber- 
culides and  pityriasis  rubra  pilaris;  (3)  the  positive  tuberculin 
reaction  which  is  obtained  in  cases  of  pityriasis  pilaris.  But  these 
proofs  are  not  sufficiently  convincing.  Since  that  time,  some 
confirmatory  cases  have  been  observed  and  a  goodly  number  of 
others  which  do  not  harmonize  with  this  interpretation.  It  is 
therefore  still  an  open  question  whether  or  not  pityriasis  rubra 
pilaris  should  be  regarded  as  a  perifollicular  tuberculide,  related 
to  lichen  scrofulosorum  and  akin  to  the  pityriasis  rubra  of  Hebra- 
-ladassohn. 

The  diagnosis  is  often  very  easy;  in  doubtful  cases,  confusion 
may  possibly  occur  with  other  peripilar  skin  diseases,  especially 
keratosis  pilaris  rubra  and  lichen  spinulosus,  or  with  the  erythro- 
dermas, with  psoriasis  and  with  lichen  planus. 

The  classical  treatment  heretofore  has  been  that  of  psoriasis: 
baths  and  soap,  with  arsenic  and  tonics  internally.  In  view  of  the 
possible  tubercular  character  of  pityriasis  rubra  pilaris,  emphasis 
must  be  placed  on  hygienic  measures,  fresh  air,  strengthening  food, 
cod-liver  oil.  Milian  was  impressed  with  the  remarkable  improve- 
ment produced  by  injections  of  tuberculin.  I  have  employed  them 
together  with  injections  of  novarsenobenzol  and  have  obtained 
encouraging  but  inconstant  results.  An  attempt  should  also  be 
made  with  radiotherapy.    [I  have  found  the  .r-ray  entirely  useless.] 


FOLLICULAR  KERATOSIS. 

In  the  folliculoses  of  this  kind,  the  inflammatory  character  is 
well-nigh  obliterated;     some  of  them  may  be  considered  as  mal- 
formations. 
26 


402  FOLLK  CLOSES 

Keratosis  Pilaris  Simplex. — This  disease,  also  known  as  lichen 
pilaris  (Bazin),  cacotrophia  folliculorum  (T.  Fox),  ichthyosis  anserina 
scrofulosorum,  xeroderma  pilaris,  is  extremely  common.  Nearly 
one-third  of  all  individuals  of  both  sexes  suffer  from  it  to  some 
degree;  it  is  hereditary  in  many  otherwise  healthy  families. 

This  fact  easts  a  doubt  on  the  relationship  of  this  affection  to 
scrofula;  it  cannot  be  simply  dismissed  as  a  tuberculide.  Its  rela- 
tions with  ichthyosis,  which  practically  always  accompanies  ostio- 
follicular  keratosis,  are  on  the  contrary  obvious. 

Keratosis  pilaris  appears  toward  the  age  of  two  or  three  years, 
flourishes  between  fifteen  and  twenty  and  subsides  at  an  adult  age. 
Mild  cases  are  the  most  common. 

It  usually  occupies  the  external  surface  of  the  arms  and  thighs, 
often  also  the  calves,  the  lower  part  of  the  legs,  the  forearms,  elbows 
and  knees,  the  waist  and  the  hips,  sparing  fatty  and  moist  regions. 

The  symptoms  consist  of  dryness  of  the  skin  with  roughening  due 
to  more  or  less  marked  acuminate  papular  elevations;  these  are 
follicular  orifices  filled  with  a  very  adherent  grayish  horny  cone,  in 
which  the  downy  hair  is  rolled  up  as  a  spiral.  The  color  of  the 
integument  is  sometimes  normal;  in  other  cases,  of  more  severe 
type,  the  follicular  constituents  are  red  or  purplish,  representing 
keratosis  pilaris  rubra. 

In  the  course  of  time,  the  shrivelled  hairs  disappear,  the  elevations 
become  flattened  and  transformed  into  punctiform  cicatrices. 

Although  of  the  nature  of  deformities  of  embryonic  origin,  like 
the  nevi,  keratosis  pilaris  takes  a  course  which  leads  to  total  atrophy 
of  the  affected  follicles  and  their  sebaceous  gland  and  to  alopecia 
of  the  invaded  regions. 

Young  girls  or  young  women  frequently  seek  advice  on  account 
of  the  roughened  condition  and  red  dots  on  their  arms.  The  same 
internal  medication  is  recommended  as  for  ichthyosis.  Locally,  it 
is  advisable  to  avoid  pumice  stone  and  rubbing  with  alcohol,  but 
the  skin  should  be  kept  anointed  with  a  fatty  substance,  a  soapy 
salve,  vaselin,  or  glycerol  of  starch  containing  salicylic  acid.  From 
time  to  time,  the  skin  should  be  cleansed  with  green  soap;  [a  salicy- 
lated  eucerin  salve  is  useful]. 

Keratosis  Pilaris  Rubra  Atrophicans  of  the  Face. — This  affection, 
named  folliculitis  rubra  by  Wilson,  ulerythema  ophryogenes  by  Unna, 
was  studied  by  Brocq,  who  pointed  out  its  connection  with  keratosis 
pilaris  simplex.  It  is  observed  in  youthful  or  adult  individuals, 
preferably  in  males. 

It  is  situated  on  the  eyebrows,  especially  at  their  outer  third, 
on  the  lower  portion  of  the  forehead  and  in  the  parotid  region; 
furthermore,  it  is  not  infrequently  combined  with  simple  keratosis 
pilaris  in  the  elective  territories  of  the  latter.     It  is  characterized 


FOLLICULAR  KERATOSIS  403 

by  a  diffuse  redness,  with  a  granular  surface  due  to  the  acuminate 
elevations  of  the  pilary  orifices,  from  which  protrude  scanty  and 
deviated  hairs.  Later  on,  the  affected  surfaces  become  bald  and  the 
beard  especially  grows  only  very  scantily;  moreover,  fine  cicatricial 
spots  are  seen,  sometimes  in  an  anastomotic  network. 

The  atrophic  tendency  is  therefore  more  pronounced  than  in 
simple  keratosis.  Brocq  has  pointed  out  the  kinship  between  this 
keratosis  rubra  pilaris  of  the  face  and  moniliform  aplasia;  the  two 
affections  may  coexist. 

In  pilary  keratosis  of  the  face,  which  is  very  obstinate,  the  con- 
dition may  be  improved  by  repeated  applications  of  green  soap; 
red  oxide  ointment  is  equally  successful.  Crossed  linear  scarifica- 
tions may  be  indicated. 

Lichen  Spinulosus. — Under  this  name,  first  used  in  England, 
several  skin  diseases  of  unknown  and  probably  different  character 
have  been  described.  Their  characteristic  symptom  consists  in  the 
presence  of  more  or  less  long  and  dry,  filiform  horny  protuberances 
emerging  from  the  pilo-sebaceous  orifices  which  are  themselves 
slightly  raised  and  of  normal  or  faintly  pink  color. 

The  lesion  is  encountered  in  youthful  individuals  and  occupies 
diffusely  the  face,  or  the  neck,  or  the  limbs,  or  the  buttocks  (acne 
cornee  of  French  authors) ;  or  it  may  be  arranged  as  circumscribed 
patches  on  the  trunk  and  the  buttocks  (acne  keratique  of  Tenneson) ; 
or  it  appears  ia  little  children  and  covers  large  surfaces  (lichen 
spinulosus  of  R.  Crocker  and  Adamson). 

The  duration  of  this  dermatosis  is  variable;  several  times  it  has 
been  known  to  disappear  spontaneously  in  a  few  weeks  or  months. 
In  one  case  I  have  found  large  numbers  of  demodex  in  the  affected 
follicles. 

Analogous  horny  protuberances  may  be  observed  in  lichen  scrof  ulo- 
sorum,  in  the  peripilar  syphilides,  etc.  It  must  therefore  be  kept  in 
mind  that  the  spinulation  is  not  the  pathognomonic  sign  of  a  single 
and  always  identical  affection. 

Ichthyosis  Follicularis. — This  term  and  that  of  keratosis  follicu- 
laris  have  been  employed  by  various  writers  to  designate  actually 
non-classifiable  affections  which  resemble  either  psorospermosis  fol- 
licularis but  without  dyskeratosis,  or  ostiofollicular  hyperkeratotic 
nevi,  etc.  A  familial  and  contagious  form  has  been  described  by 
Brooke. 

In  the  differential  diagnosis  of  these  various  follicular  keratoses, 
it  must  be  remembered  that  lichen  planus  may  exceptionally  assume 
the  form  of  acuminate  papules ;  that  pityriasis  rubra  pilaris  includes 
numerous  incomplete,  entirely  localized  cases;  that  spinulation  is 
encountered  in  several  diseases;  finally,  that  the  follicular  syphilides 
are  sometimes  discrete  and  often  very  polymorphous. 


CHAPTER    XX. 
TRICHOSES. 

The  name  "trichoses"  (0pi£,  tPlx6s  =  hair)  is  applied  to  the 
diseases  and  anomalies  of  the  hairs  on  the  head  and  body. 

The  hairs  are  filiform  corneal  structures  whose  root  is  inserted 
in  the  pilary  follicles;  they  are  a  secretory  product  of  the  terminal 
papilla  of  these  follicles  which  they  cover  with  their  enlarged 
extremity,  known  as  the  bulb.  This  bulb  is  hollow  while  the  hair 
is  still  growing;  it  closes  up  and  becomes  solid  when  the  hair  has 
completed  its  development  and  is  ready  to  fall  out.  When  a  hair 
has  fallen  out  or  been  forcibly  removed,  unless  the  deep  portion  of 
the  follicle  has  been  destroyed,  it  is  replaced  as  a  rule  by  another 
hair,  which  forms  in  a  diverticulum  of  the  original  follicle. 

The  structure  of  the  hairs  is  very  simple.  They  consist  of  more 
or  less  pigmented  elongated  corneal  cells,  forming  what  is  known  as 
the  cortex  of  the  hair;  of  an  external  cuticle;  and  of  a  central  medul- 
lary canal,  which  may  be  absent. 

Under  the  heading  of  trichoses  belong:  (1)  the  hypertrichoses; 
(2)  the  hypotrichoses  or  alopecias;  (3)  the  dystrophic  trichoses;  (4) 
the  parasitic  diseases  of  the  hairs. 

Obviously,  it  would  be  logical  to  group  the  majority  of  the  trichoses 
with  the  folliculoses.  As  a  matter  of  fact,  a  pilary  hypcrproduction 
or  an  alopecia  is  the  manifestation  of  a  trophic  disturbance  of  the 
papilla  of  the  hair;  in  the  tineas,  the  parasites  attack  simultaneously 
the  root  of  the  hair  and  its  sheaths.  But  this  follicular  lesion  is  not 
apparent;  the  striking  feature  consists  in  the  malformation,  fall, 
absence  or  alteration  of  the  hairs.  In  accordance  with  the  plan  of 
this  book  I  shall  therefore  devote  a  special  chapter  to  the  trichoses. 

HYPERTRICHOSES. 

Hypertrichosis,  an  anomaly  consisting  in  an  overproduction  of 
hairs  which  are  larger,  more  abundant  and  more  highly  pigmented 
than  is  appropriate  for  the  affected  region  or  the  age  and  sex  of  the 
subject  does  not  always  represent  the  same  type  of  disease.  Some- 
times, it  accompanies  congenital  hyperkeratosis.  The  pure  eases 
should  be  grouped,  as  already  indicated  by  Virchow,  into  three 
classes,  between  which  intermediate  forms  are  encountered. 


H  YPER  TRW  HOSES 


405 


1.  Nevl  yilosi  are  very  common,  often  multiple,  small  and  lentic- 
ular, or  very  extensive  and  may  cover  large  areas  (Fig.  129,  A) 
Even  when  they  are  not  verrucous,  the  skin  is  usually  pigmented  and 


-Three  types  of  hypertrichosis.     A,  nevi  pilosi;  B,  hypertrichosis  fetalis; 
C,  true  hypertrichosis  of  masculine  type. 


nevus  cells  may  be  found  in  it.  They  are  as  a  rule  sharply  circum- 
scribed. Their  arrangement  is  not  perfectly  symmetrical.  They 
may  develop  after  birth. 


406  TRtCtiOSES 

2.  Hypertrichosis  fetalis    or  lanuginous  pseudohypertrwliosts  of 

Bonnet  —is  seen  in  so-called  wild  men  or  human  canines  and  consists 
in  the  abnormal  persistence  of  the  fetal  hairs  which,  moreover,  are 
hypertrophied.  It  is  symmetrical,  increases  with  age,  occupies 
regions  which  even  in  persons  with  a  very  strongly  developed  hairy 
system  are  rather  smooth,  like  the  forehead  and  the  nose.  The 
hairs  are  wooly,  soft  and  curly.  The  affected  individuals  usually 
present  serious  dental  anomalies.  Yirchow  designated  this  form  as 
hypertrichosis  of  fin'  edentata  (Fig.  12!)  B). 

3.  True  hypertrichosis  must  be  considered  separately  in  the  two 
sexes. 

In  men  it  is  merely  an  exaggeration  of  the  normal  state  which  is 
itself  extremely  variable.  It  does  not  really  manifest  itself  until 
puberty  which  may  be  premature.  Together  with  an  abundant 
hairy  growth  of  the  beard  and  other  hairy  regions,  an  almost  ape- 
like hairy  proliferation  may  appear  symmetrically  on  the  chest, 
back  and  limbs;  sometimes  the  hypertrichosis  predominates  in 
the  sacral  region,  forming  the  tuft  which  the  ancients  considered  as 
an  attribute  of  the  fauns. 

Masculine  hypertrichosis  is  not  uncommonly  hereditary  or 
atavistic.  It  has  been  observed  to  occur  not  infrequently  in  tuber- 
culous individuals. 

In  women,  hypertrichosis  of  the  masculine  type  constitutes  the 
form  which  is  of  chief  interest  to  the  dermatologist. 

The  patients  are  usually  young  girls  or  young  women  who  have 
noticed  since  puberty,  first  the  development  of  a  troublesome  downy 
growth,  followed  by  hypertrophied  hairs  on  the  upper  lip,  the  chin, 
or  the  cheeks  and  more  rarely  by  complete  beards  made  up  of 
15  to  20  thousand  hairs  (Fig.  129,  C).  In  some  eases,  the  chest,  the 
breasts,  or  the  limbs  are  the  seat  of  this  abnormal  hairy  growth. 

These  hypertrichoses  of  young  girls  not  unfrequently  is  the 
occasion  of  a  real  pathological  obsession,  known  as  trichomania, 
which  plunges  them  into  despair  and  melancholia,  even  in  cases 
where  the  down  is  hardly  disfiguring. 

Much  more  common  is  the  appearance  of  large  hairs  on  the  chin, 
or  of  a  moustache  in  women  of  thirty  to  forty  years  or  especially 
at  the  time  of  the  menopause. 

The  cause  of  this  deformity  is  sometimes  hereditary;  a  natural 
tendency  is  apt  to  become  aggravated  by  local  irritations,  the 
employment  of  depilatory  pastes  or  of  the  razor  and  especially  by 
epilation  with  the  forceps.  On  the  other  hand,  there  undoubtedly 
exists  a  possible,  but  actually  very  inconstant  relation  between 
hypertrichosis  of  the  masculine  type  and  the  genital  functions. 

This  relation  is  indicated  by  eases  of  precocious  menstruation  and 
sexual  maturity  in  hypertrichotie  individuals  on  the  one  hand  and 


ALOPECIAS  407 

on  the  other  by  the  hypertrichosis  of  the  menopause.  Lesser 
observed  a  girl  of  six  years  who  had  menstruated  since  the  age  of 
three,  had  the  breasts  of  an  adult  female  and  was  more  hairy  than 
a  man  of  thirty  years. 

In  both  sexes,  repeated  local  irritation,  scratching,  phototherapy, 
etc.,  may  give  rise  to  regional  hypertrichoses.  Other  cases  are  of 
kerotic  origin. 

According  to  observations  made  in  the  course  of  the  war,  by  G. 
and  M.  Villaret  and  others,  a  hypertrichosis  which  develops  on  the 
cutaneous  territory  of  a  traumatized  nerve  generally  coincides  with 
hyperidrosis  and  with  the  absence  of  the  reaction  of  degeneration 
and  indicates  an  incomplete  injury,  not  a  definite  lesion  of  the  nerve. 
Inversely,  a  hypotrichosis  originating  under  the  same  conditions  is 
usually  accompanied  by  the  reaction  of  degeneration  and  indicates 
a  complete  interruption  of  the  nerve. 

Treatment. — The  question  of  treatment  arises  only  in  cases  of 
hypertrichosis  in  young  girls  and  women.  At  the  onset,  it  is  especi- 
ally necessary  to  forbid  all  local  irritations  and  especially  epilation. 

Too  plainly  visible  downy  hairs  may  be  bleached  with  strong 
hydrogen  peroxide  solutions  after  all  fat  has  been  removed,  or  a 
peroxide  cream  may  be  prescribed.  A  salve  made  with  thallium 
acetate  (1  per  cent.)  will  cause  a  large  proportion  of  the  hairs  in 
the  medicated  region  to  drop  out,  but  has  the  disadvantage  of  under- 
going absorption  and  thereby  acting  at  the  same  time  on  the  hairy 
scalp  and  the  eyebrows. 

When  the  hairs  are  really  excessively  large  no  recourse  is  left  but 
electrolytic  epilation,  which  is  radical,  not  particularly  painful, 
leaves  hardly  visible  cicatrices  when  properly  performed  but  is 
very  tedious  when  the  hairs  are  at  all  numerous.  For  the  technic, 
the  reader  is  referred  to  special  contributions,  especially  by  Brocq, 
who  has  carefully  investigated  this  question. 

Radiotherapy  is  often  demanded  by  these  patients,  but  cannot 
at  present  be  recommended. 

Outside  of  the  hairy  scalp,  its  epilating  action  is  unreliable  and 
too  dangerous  to  employ;  in  large  doses,  it  exposes  to  very  unde- 
sirable pigmentations  and  incurable  spots  of  radiodermatitis 
atrophicans  developing  after  a  few  years.  In  weak  doses,  a  renewed 
and  sometimes  exaggerated  growth  may  be  expected  after  a  variable 
length  of  time. 

ALOPECIAS. 

The  term  alopecia  {aKccivr]^  =  fox)  is  indiscriminately  applied 
to  the  fall  of  scalp  or  lanugo  hairs  (defiuvium) ,  to  the  resulting 
hairlessness  and  even  to  the  congenital  absence  of  hair. 

The  congenital  alopecias  [atrichia]  are  very  rare  and  often  familial ; 


408  TRICHOSES 

in  their  distribution  they  are  diffuse  or  regional  and  occasionally 

circumscribed.  The  piiary  agenesia  may  be  pure,  or  essential;  or 
it  may  be  associated  with  nevi,  congenital  hyperkeratosis,  keratosis 
pilaris,  monilethrix,  more  or  less  pronounced  cutaneous  atrophy,  etc. 

The  acquired  alopecias  are  divided  into  two  classes,  according  to 
their  being  diffuse  and  regional,  or  on  the  contrary  circumscribed. 
The  hairy  scalp  is  their  seat  of  predilection  and,  unless  otherwise 
indicated,  the  following  remarks  will  deal  particularly  with  this 
region. 

Regional  and  Diffuse  Alopecias. — Traumatic  Alopecias. — Certain 
traumatic  alopecias  are  diffuse.  The  scalp  or  body-hairs  may  have 
been  pulled  out,  accidentally,  with  a  therapeutic  object  or  for 
purposes  of  simulation.  The  name  trichotillomania  designates  a 
sort  of  tic  or  bad  habit  which  causes  some  persons  incessantly  to 
pull  or  tear  out  the  hairs  of  a  given  region. 

Contusions  and  wounds  give  rise  only  to  circumscribed  alopecias. 
But  the  rubbing  of  the  head  on  the  pillow,  especially  at  the  occipital 
and  parietal  prominences  in  some  weakly  or  hydrocephalic  children; 
friction  of  the  vertex  in  women,  caused  by  combs  or  coiffures; 
friction  of  the  clothing  on  the  wrists  or  legs;  scratching  in  conse- 
quence of  pruritus — all  of  these  induce  deterioration  and  falling  of 
the  hairs,  a  condition  which  may  be  grouped  under  the  heading  of 
traumatic  alopecia. 

Pathological  Alopecias. — These  are  much  more  common.  It  would 
be  logical  and  may  seem  easy  a  priori  to  subdivide  them  into  two 
groups,  according  as  the  fall  of  the  hairs  depends  upon  a  local 
affection  or  is  the  result  of  a  disturbance  of  the  general  health,  such 
as  an  infectious,  dyscratic,  or  cachexia-inducing  disease. 

Sometimes  the  local  affection  is  evident:  In  this  way  an  eczema 
of  the  hairy  regions,  the  exfoliative  erythrodermas  and  very  exten- 
sive  tineas,  may  lead  to  diffuse  alopecia.  I  shall  not  dwell  on  this 
class  of  eases,  the  diagnosis  of  which  is  very  easy,  the  treatment 
being  that  of  the  causative  disease. 

In  other  cases  the  hairy  scalp  appears  healthy;  here  an  investi- 
gation will  disclose  the  existence  of  one  of  the  general  diseases  which 
will  be  discussed  further  on. 

In  the  vast  majority  of  the  cases  of  diffuse  alopecia,  however, 
only  mild  or  ordinary  lesions  are  found  on  the  alopecic  skin,  such 
as  pityriasis,  seborrhea,  etc.,  which  one  may  hesitate  to  consider  as 
causative.  These  conditions  are  interpreted  by  some  writers  as 
accessory  and  irrelevant,  by  others  as  the  actual  cause  of  the 
alopecia,  in  my  opinion,  these  various  pathological  phenomena  are 
not  interdependent,  but  are  all  alike  derived  from  kerosis. 

Kerotic  Alopecia  and  Calvities. — Kerosis  is  the  name  which  I 
apply  to  an  extremely  frequent  cutaneous    dystrophy,  shown    by 


ALOPECIAS  409 

combined  manifestations  such  as  pityriasis  simplex,  seborrhea, 
hyperidrosis  and  nutritional  disturbances  of  the  pilary  system,  in 
the  form  of  hypertrichosis  or  alopecia.  In  different  cases,  one  or 
several  of  these  symptoms  may  predominate. 

It  is  customary  to  consider  as  special  pathological  types  and  to 
describe  separately,  alopecia  with  seborrhea  {alopecia  seborrheica) 
with  pityriasis  {alopecia  pityrodes,  pellicularis,furfuracea) ,  and  the  ap- 
parently essential  alopecia  {alopecia  senilis,  prematura  and  cahities). 

However,  these  types  are  very  imperfectly  defined  and  can  be 
included  in  one  and  the  same  description,  a  few  words  sufficing  to 
point  out  the  different  clinical  varieties  of  kerotic  alopecia. 

On  the  scalp,  its  seat  of  predilection,  kerotic  alopecia  is  diffuse, 
but  regional  and  progressive.  It  begins  at  the  vertex,  at  the  place 
of  the  tonsure  and  at  the  sides  of  the  forehead.  As  it  progresses  it 
becomes  generalized  and  spreads  at  an  extremely  variable  rate. 
It  may  stop  half-way  or  even  retrograde  slightly  in  youthful  and 
properly  treated  individuals.  Often,  however,  it  progresses  inexor- 
ably, denuding  the  entire  top  of  the  head ;  it  spares  for  a  fairly  long 
time  a  median  island  at  the  top  of  the  forehead  and  almost  always 
definitely  the  temporal  and  lower  occipital  regions,  so  that  a  semi- 
circle of  hairs  is  left  passing  from  one  temple  to  the  other  across 
the  nape  of  the  neck. 

Before  becoming  detached,  the  bulb  of  the  hairs  has  become  solid 
and  they  will  then  yield  to  the  slight  traction  of  the  brush,  etc.;  a 
few  days  later  they  fall  out  spontaneously. 

The  fall  may  be  continuous,  or  it  may  occur  paroxysmally  in 
variable  degrees.  Although  there  are  in  this  respect  great  individual 
variations  or  differences  according  to  age,  season  of  the  year,  mode 
of  life,  etc.,  a  scalp  which  regularly  loses  from  thirty  to  forty  hairs 
daily  may  certainly  be  said  to  be  in  course  of  denudation  and  the 
ratio  of  the  daily  fall  is  often  much  higher. 

The  fallen  hairs,  which  at  first  are  healthy  and  of  normal  calibre, 
are  always  replaced;  but  the  successive  generations  are  more  and 
more  delicate,  until  they  are  finally  represented  merely  by  a  fine 
down,  which  may  disappear  in  its  turn.  The  resulting  condition  is 
total  baldness  {cahities  hippocratica) .  The  skin  of  the  scalp  becomes 
white,  smooth,  glistening,  polished,  and  seems  to  be  atrophied  or  at 
least  slightly  thinned. 

In  the  course  of  the  development  of  the  disease,  the  scalp  has 
almost  invariably  become  affected  with  the  oily  scales  of  pityriasis, 
with  seborrhea  and  hyperidrosis.  For  a  time  there  may  have  been 
a  production  of  scaly  crusts  or  more  or  less  circumscribed  and  figured 
surfaces,  accompanied  by  pruritus;  as  a  matter  of  fact,  eczematides 
are  common  on  the  scalp  of  kerotic  individuals  and  may  recur  in 
bald  persons  who  neglect  personal  cleanliness. 


410  TRICBOSMS 

Varieties.-    As  stated  above,  the  varieties  of  kerotic  alopecia  are 

very  imperfectly  defined. 

According  to  authors,  alopecia  seborrheica  is  said  to  be  precocious 

and  rapid  in  its  development,  plainly  regional  and  strongly  denud- 
ing; alopecia  pityr'odes  referring  to  fatty  pityriasis,  as  the  dry  pity- 
riasis is  not  depilating  (Sabouraud) — is  said  to  be  more  diffuse  and 
always  incomplete;  alopecia  senilis  is  supposed  to  depend  upon 
cutaneous  atrophy  and  to  be  unrelated  to  seborrhea  and  pityriasis; 
it  is  slowly  progressive  and  the  most  relentless  in  its  advance; 
alopecia  prematura,  often  familial,  may  begin  toward  the  age  of 
twenty  years  and  cause  baldness  at  twenty-five  or  earlier,  but  has  such 
variable  features  that  its  pathogenesis  is  by  no  means  agreed  upon. 

In  women,  notably  in  young  girls  and  young  women,  an  abundant 
fall  of  hairs  is  very  common  in  recurrent,  sometimes  seasonal  periods, 
with  more  or  less  fatty  pityriasis ;  but  it  only  exceptionally  leads  to 
baldness.  The  latter  is  seen  in  aged  women  and  occupies  the  temples 
as  well  as  the  sinciput. 

Xerotic  alopecia  of  the  beard,  the  moustache,  the  eyebrows  and 
cilia,  is  much  less  common  and  accompanies  as  a  rule  fatty  pityriasis 
or  still  more  frequently  the  eczematides  of  these  regions;  it  is  incom- 
plete and  always  temporary.  Bald  individuals  usually  have  a  fine 
full  beard. 

On  the  trunk,  notably  on  the  chest,  kerosis  produces  on  the  con- 
trary a  definite  loss  of  hair  in  many  cases,  with  persistence  of  a  few 
thick  scattered  hairs. 

Etiology. — Having  previously  discussed  the  etiological  factors  of 
kerosis,  I  may  here  limit  myself  to  stating  that  mental  overexertion, 
night  work,  a  poor  dietary  hygiene  and  in  fact  also  a  poor  hygiene 
of  the  scalp,  dressing  the  hair  brush-fashion,  heavy  and  badly  venti- 
lated skull-caps,  etc.,  seem  to  predispose  to  progressive  alopecia. 

Very  frequently  the  ordinary  causes  become  combined  with  some 
of  the  pathological  conditions  discussed  in  the  next  section,  con- 
valescence, anemia,  dyspepsia,  etc.,  so  that  the  differential  diag- 
nosis between  kerotic  alopecia  and  alopecia  of  general  diseases  is 
often  extremely  difficult  and  even  impossible  in  combined  cases. 
The  prognosis  must  therefore  be  guarded. 

|  W<  >men  rarely  are  bald ;  men  rarely  lose  their  beards.  In  fact  the 
same  conditions  affecting  the  scalp  and  the  bearded  region  in  a  man 
may  cause  a  complete  alopecia  of  the  scalp  while  scarcely  thinning 
the  beard.  May  we  not  seek  the  explanation  of  the  relatively 
greater  resistance  of  the  man's  beard  and  the  woman's  hair  in  an 
underlying  biological  fact?  The  beard  of  the  male  and  the  long 
hair  of  the  female  scalp  are  secondary  sex  characteristics  and  as 
such  might  be  expected  to  possess  a  greater  inherent  resistance  to 
injury  than  a  useless  structure  like  the  hair  on  the  male  head.] 


ALOPECIAS  411 

Treatment. — After  having  corrected,  if  practicable,  all  that  is 
deficient  in  the  hygiene  and  health  of  the  patient,  the  kerosis  must 
be  treated  systematically  and  for  a  long  time  with  reducing  agents, 
sulphur  preparations,  tar  and  mercurial  lotions,  etc.  Later  on, 
various  stimulating  lotions  may  be  prescribed.  By  these  means, 
the  trouble  is  very  often  successfully  checked,  or  rather  the  fatal 
outcome  may  be  delayed. 

In  established  baldness,  I  have  seen  a  few  cases  of  patients,  who 
persisting  in  very  prolonged  and  energetic  treatment,  acquired  a 
few  strong  hairs  on  the  denuded  surface,  but  they  remain  thinly 
scattered  and  the  result  is  by  no  means  satisfactory  from  the 
esthetic  point  of  view. 

Alopecias  of  General  Diseases. — A  large  number  of  acute  infectious 
diseases — typhoid  fever,  erysipelas,  pneumonia,  grippe,  the  eruptive 
fevers,  the  erythrodermas,  etc. — are  followed  during  convalescence 
or  after  a  few  weeks'  delay  by  a  diffuse  acute  alopecia.  The  same 
may  result  as  a  sequel  of  childbirth,  severe  operations,  serious 
traumatisms,  violent  emotional  disturbances. 

The  fall  of  hairs  in  these  cases  may  be  slightly  marked  or  so 
abundant  that  the  hair  comes  out  in  handfuls  and  the  denudation 
is  practically  complete  in  a  few  days,  constituting  the  defluvium 
capillitii  of  the  ancients.  The  alopecia  may  also  involve  the  hairs 
of  the  body.  The  present  pandemic  of  influenza  has  produced  an 
extraordinary  number  of  cases  of  alopecia.  [The  defluvium  usually 
develops  about  two  months  after  convalescence.] 

When  the  scalp  is  not  pityriasic,  it  is  useless  to  cut  the  hairs  which 
are  left;  some  stimulating  washes  suffice  and  the  hair  grows  in  again 
as  abundantly  as  before  the  disease. 

Syphilitic  Alopecia. — This  condition  may  be  considered  to  some 
degree  as  a  peculiar  instance  of  this  class.  It  occurs  very  commonly 
from  the  third  to  fifteenth  month  after  the  infection.  Its  onset  is 
often  insidious.  The  scalp  is  not  necessarily  the  seat  of  eruptions, 
crusts,  etc.,  but  there  is  often  a  combination  with  pityriasis. 

There  is  sometimes  a  mere  thinning  of  the  hair,  sometimes  a 
regional  alopecia  [alopecia  areolata]  which  is  almost  pathognomonic, 
with  its  incompletely  denuded  areas  oscupying  especially  the 
temporal  regions  and  the  occiput.  [The  alopecia  which  is  pathog- 
nomonic is  what  may  be  described  as  having  a  "moth-eaten" 
appearance.]  The  coexistence  of  a  pigmentary  syphilide  of  the  neck 
is  not  uncommon. 

This  syphilitic  alopecia  must  not  be  confused  with  pyodermic 
alopecia  or  with  the  alopecia  areata  whose  patches  even  when 
numerous  are  usually  more  completely  denuded  and  more  sharply 
outlined.  Syphilitic  alopecia  may  also  affect  the  hairs  of  the  body, 
the  beard,  the  eyebrows  and  especially  the  outer  end  of  the  eye- 


412  TRICHOSES 

brows.  The  hair  always  grows  again,  for  "syphilis  makes  no  bald 
heads"  (A.  Fournier). 

hi  all  the  infectious  alopecias,  a  paralysis  of  the  pilary  papillae 
is  apparently  produced  under  the  influence  of  toxins,  comparable 
to  that  which  affects  the  matrix  of  the  nails  under  the  same  con- 
ditions; a  very  large  number  of  hairs  at  once  assume  a  solid  bulb. 
The  condition  is  therefore  a  sort  of  pathological  moulting. 

The  absorption  of  thallium  salts  produces  a  total  alopecia  com- 
parable in  every  way  with  the  infectious  alopecias. 

Chronic  diseases,  anemia,  diabetes,  cancer,  myxedema,  exophthal- 
mic goitre,  mycosis  and  the  leukemias,  utero-ovarian  diseases  or 
spaying  in  women,  depressing  mental  diseases,  affections  of  the 
liver  and  intestines  and  still  more  frequently  tuberculosis,  give  rise 
to  chronic,  diffuse,  progressive,  alopecias  which  must  be  traced  to 
their  true  origin.  In  leprosy,  the  hairs  of  the  face  in  general  and 
those  of  the  body  fall  out,  whereas  the  hairy  scalp  escapes. 

Circumscribed  Alopecias. — The  first  point  to  be  settled  in  deal- 
ing with  a  non-congenital  circumscribed  alopecia  is  to  decide  if  it  is 
cicatricial  or  not. 

In  a  case  of  cicatricial  alopecia,  the  surface,  grain,  sheen,  color, 
consistence  and  sometimes  the  mobility  of  the  skin  are  modified; 
the  hair-follicles  have  entirely  disappeared ;  atrophic,  brittle,  downy 
hairs  are  never  present;  when  some  hairs  are  left,  they  are  of  normal 
calibre. 

Cicatricial  alopecia  may  result  from  a  wound,  a  burn,  a  caustic 
agent,  or  it  may  follow  upon  favus,  patches  of  lupus  erythematodes 
or  scleroderma,  ulcerative  tertiary  syphilides,  pseudopelade,  acne 
decalvans,  etc.  The  denudation  is  permanent.  The  local  exami- 
nation and  clinical  history  will  clearly  indicate  the  origin. 

A  non-cicatricial  alopecia  is  primarily  suggestive  of  alopecia 
areata.  In  the  first  place  it  is  necessary  to  exclude  traumatic 
alopecia  or  a  voluntary  epilation,  as  observed  in  schools  and 
barracks,  also  an  existing  dermatosis,  such  as  eczema,  eczematide, 
impetigo,  etc.,  which  are  easily  recognizable. 

It  is  noteworthy  that  impetigo,  furuncle  and  suppurations  in 
general,  ordinarily  have  behind  non-cicatricial,  distinctly  outlined, 
round  alopecic  spots,  the  size  of  a  dime  to  that  of  a  silver  dollar,  on 
which  the  re-growth  of  at  first  downy  then  normal  hairs  may  be 
delayed  for  several  months. 

These  post-impetiginous  alopecias,  better  named  pyodermic  alope- 
cias-, due  to  a  local  blasting  of  the  hairy  territory  by  the  toxins  of 
the  pyococci,  are  common  in  children  and  are  often  mistaken  for 
alopecia  areata.  They  are  characterized  by  the  macule  which 
may  be  observed  in  their  center  and  by  the  clinical  data.  A  stimu- 
lating lotion  suffices  for  their  cure. 


ALOPECIAS  413 

Alopecia  areata  (la  pelade)  [area  celsi]  is  the  most  important  of 
the  circumscribed  alopecia-producing  dermatoses.  There  exists  a 
generalized  form,  known  as  alopecia   decahans  [or  totalis]. 

Alopecia  areata  is  characterized  by  smooth,  sharply  outlined, 
round  or  oval  spots  or  patches  of  variable  dimensions  and  number, 
occupying  especially  the  scalp  and  the  beard.  These  spots  appear 
insidiously,  as  a  rule  without  any  particular  sensation.  Denudation 
of  hair  is  rapid,  by  tufts,  within  a  few  days;  it  may  then  slowly 
spread  eccentrically,  or  over  a  part  of  the  periphery  of  the 
spot. 

The  fall  of  the  hairs  follows  upon  preceding  imperceptible  changes ; 
they  fall  out  with  a  solid  bulb,  many  have  atrophic  roots;  further- 
more, broken  atrophic,  so-called  alopecia  hairs  are  found  at  the 
periphery  of  the  patch,  or  even  at  a  distance  when  it  is  about  to 
extend. 

These  characteristic  alopecia  hairs,  very  abundant  in  some  cases 
(alopecias  with  fragile  hairs,  of  Besnier),  very  rare  in  the  beard,  are 
from  2  to  6  mm.  long,  pointed  like  a  [wet]  brush  at  the  ends,  black 
halfway  or  in  the  distal  two-thirds,  very  thin,  tapering  and  decolor- 
ized toward  the  root,  which  terminates  in  a  slight  swelling;  they  are 
accordingly  club-shaped  or  like  a  note  of  exclamation.  Being  very 
superficially  inserted,  they  are  very  easily  pulled  out  with  forceps, 
never  breaking  off. 

Fresh  patches  are  often  rose-colored,  slightly  edematous,  riddled 
with  dilated  pilary  orifices  containing  seborrheic  utricles  (Sabou- 
raud).  After  some  time,  the  spot  becomes  depressed,  ivory  white, 
entirely  smooth,  soft  to  the  touch  and  easily  folded.  This  stage  was 
called  achromatous  alopecia  by  Bazin. 

A  healing  patch  becomes  covered  with  downy  hairs  which  at  first 
are  thin,  pale  and  very  loosely  implanted;  these  are  replaced  by 
stronger  downy  hairs  and  finally  by  normal  hairs,  actually  thicker 
and  darker  than  the  original,  but  sometimes  on  the  contrary  white. 
The  new  growth  may  be  central  and  centrifugal,  or  it  may  be 
centripetal. 

The  areas  of  alopecia,  very  variable  in  number,  are  situated  at 
any  point  of  the  scalp,  perhaps  more  frequently  near  the  vertex, 
on  the  parietal  and  the  occiput;  anywhere  in  the  beard,  especially 
on  the  sides  of.  the  chin;  more  rarely  on  the  eyebrows  and  lids,  as 
well  as  on  other  hairy  regions  of  the  body.  A  symmetrical  tendency 
has  been  noted  in  some  cases  and  on  the  other  hand  a  regional  dis- 
tribution in  others. 

As  varieties  may  be  described :  a  form  with  multiple  small  spots, 
resembling  syphilitic  alopecia;  a  form  with  a  large  patch  extending 
like  a  crown  from  the  nape  of  the  neck,  above  the  temples  and  to 
the  forehead;  this  is  the  ophiasis  of  Celsus  or  alopecia  coronarius 


I  I  I  TRIC HOSES 

peculiar  to  children,  according  to  Sabouraud;  it  is  especially  obsti- 
nate as  are  all  the  alopecias  which  affect  the  border  of  the  scalp. 

Alopecia  decahans  is  the  most  serious  variety.  It  begins  like  the 
ordinary  form  often  in  very  extensive  areas  which  remain  limited 
for  several  days  or  even  several  months.  Suddenly,  in  a  few  days, 
the  alopecia  then  becomes  generalized  over  the  entire  or  nearly  the 
entire  scalp,  face  and  body,  sometimes  leaving  a  tiny  tuft  or  a  few 
islands  of  hair.  In  this  last  named  form  are  sometimes  seen  a 
relaxation  of  the  skin  permitting  it  to  be  easily  folded,  i.  e.,  hypo- 
tonia; and  lesions  of  the  nails,  which  will  be  discussed  elsewhere. 
Slight  sensory  disturbances  have  been  noted  on  the  smooth  surfaces, 
cryesthesia,  hypoesthesias,  etc. 

The  course  of  alopecia  areata  is  very  variable.  Mild  cases  are 
cured  in  two  to  six  months.  Recurrences,  appearance  of  new 
patches  before  the  first  have  healed  and  relapses  at  any  time  are 
extremely  common.  There  occur  cases  of  incessant  renewal  and 
fall.  Alopecia  decahans  lasts  from  one  to  four  years  and  is  entirely 
cured  in  youthful  individuals,  incompletely  in  older  patients. 

Etiology  and  Nature. — Twenty  years  ago,  alopecia  areata  was 
almost  universally  believed  to  be  parasitic  and  contagious;  at  least 
a  contagious  form  was  admitted.  The  stories  of  epidemics  in  schools 
and  barracks,  quoted  in  support  of  this  contention,  were  scattered 
and  blown  away  like  smoke  as  soon  as  it  could  be  recognized  by 
careful  investigation  that  there  was  always  a  coincidence  of  sporadic 
cases  with  cicatrices  and  various  pseudo-alopecias  or  with  ring- 
worm. Credit  is  due  to  Lucien  Jacquet  for  his  indefatigable  work 
in  proving  the  non-contagiosity  of  pelade;  his  thousands  of  experi- 
mental inoculations  on  himself  and  on  already  affected,  therefore 
predisposed,  subjects,  did  not  yield  a  single  positive  result. 

In  favor  of  a  nervous  origin  of  alopecia  areata  have  been  quoted 
the  experiments  of  Max  Joseph  who  through  division  of  the  occipital 
nerves  in  cats  produced  bald  spots  which,  as  a  matter  of  fact,  had 
only  an  apparent  analogy  with  alopecia  areata;  and  on  the  other 
hand,  the  not  uncommon  coincidence  of  alopecia  areata  with 
neuralgias,  headaches  and  an  "unbalanced"  nervous  state. 

In  the  dystrophic  theory  of  Jacquet,  the  predisposing  role  was 
attributed  either  to  a  complex  organic  deterioration,  as  indicated 
by  urinary  analysis,  or  to  hereditary  factors.  On  the  soil  thus 
prepared,  the  alopecia  was  assumed  to  be  elicited  and  focussed 
through  local  peripheral,  or  visceral,  or  central  irritations.  Among 
the  irritations  starting  the  reflex,  those  of  dental  origin  are  the  most 
common;  very  often  the  eruption  of  the  teeth,  more  particularly 
the  wisdom  teeth,  or  dental  caries,  alveolar  inflammations,  badly 
fitting  dentures  and  so  forth  can  be  held  responsible.  There  is 
even  a  certain  relation  between  the  localization  of  the  bald  areas 
and  that  of  the  irritative  focus. 


ALOPECIAS  415 

Taking  up  the  question  ab  ovo,  Sabouraud  and  his  school  started 
of  recent  years  a  new  inquiry  concerning  the  etiology  of  pelade.  It 
appears  that  this  affection  is  hereditary  or  familial  in  at  least  22 
per  cent,  of  the  cases;  the  affection  is  only  half  as  frequent  in  the 
female  as  in  the  male  sex;  its  maximal  frequency  of  onset  is,  in  both 
sexes,  between  the  age  of  six  and  twelve  years;  it  is  furthermore 
observed  with  relative  frequency  in  women  at  the  time  of  the 
menopause  or  after  a  prolonged  suppression  of  menstruation, 
through  spaying,  for  example,  and  more  rarely  in  the  course  of 
pregnancy. 

Statistics  finally  show  a  connection  between  alopecia  areata  and 
thyroid  disturbances,  especially  exophthalmic  goitre,  where  it  is 
apt  to  be  chronic  and  severe.  As  to  the  etiological  relations  with 
acquired  or  congenital  syphilis,  these  are  neither  clear  nor  direct; 
syphilis  could  be  demonstrated  in  only  about  10  per  cent,  of  the 
cases  of  alopecia  areata. 

These  data  are  undoubtedly  interesting,  but  on  the  whole  it 
must  be  admitted  that  the  real  nature  of  alopecia  areata  still 
remains  unknown. 

Treatment. — Since  it  is  known  that  alopecia  areata  is  never  and  in 
no  degree  contagious,  the  prophylaxis  of  this  affection  has  assumed 
an  altogether  different  direction.  There  is  now  no  reason  to  isolate 
the  patients  or  to  keep  them  away  from  gatherings,  schools,  work- 
shops, barracks,  etc.,  to  refuse  them  a  clean  bill  of  health,  nor  to 
suspect  hairdressers  or  barbers,  caps,  hats,  pillows,  etc.,  of  having 
transmitted  a  disease  which  is  non- transmissible. 

The  treatment  of  alopecia  areata  and  the  prophylaxis  of  relapses 
or  recurrences,  are  therefore  purely  individual. 

An  effort  must  be  made  in  a  given  case  to  determine  the  existing 
factors  of  nervous  and  trophic  loss  of  balance,  in  order  to  treat  its 
general  and  deep  causes.  In  the  presence  of  overstrain,  bad  hygienic 
conditions,  organic  or  functional  disturbances,  it  may  be  necessary 
to  recommend  relative  rest,  life  in  the  open  air,  in  the  country  or  the 
mountains;  dry  or  alcoholic  friction  of  the  entire  body;  hydro- 
therapy in  its  tonic  or  sedative  forms,  or  perhaps  various  opothera- 
peutic  measures,  or  the  reconstructives,  phosphates,  arsenic,  etc. 

On  the  other  hand  it  is  very  important  to  look  for  the  localizing 
causes,  as  it  were.  A  bad  condition  of  the  teeth  and  gums  requires 
attention,  even  in  the  absence  of  pain,  congestion,  neuralgia,  etc. 
This  point  must  be  emphasized ;  I  have  personally  seen,  like  Jacquet, 
a  considerable  number  of  cases  which  had  resisted  all  local  medica- 
tion heal  of  their  own  accord  with  suggestive  rapidity  after  expert 
treatment  at  the  hands  of  a  dentist.  Sometimes  the  "peladogenic" 
focus  is  to  be  found  in  the  ears,  nose  or  pharynx  and  one  must 
proceed  accordingly. 


416  TRICHOSES 

The  local  measure*  may  he  summarized  as  follows:  repeated, 
sufficiently  energetic  but  not  exaggerated  stimulation  of  the  denuded 
areas.  This  stimulation  may  be  mechanical,  being  obtained  by 
massage,  petrissage,  brushing,  twice  daily  or  oftener;  in  the  stage 
of  re-growth,  it  must  be  remembered  that  of  all  stimulants  epilation 
acts  the  most  directly  upon  the  pilary  papillae.  Chemical  stimu- 
lation may  be  accomplished  by  means  of  iodized,  acetic  or  ammoni- 
acal,  chloroform  or  alcoholic,  or  other  mixtures  selected  from  the  list 
of  stimulating  and  rubefacient  lotions;  the  applications  should  be 
made  every  day  or  at  longer  intervals.  [Pure  liquified  phenol 
allowed  to  act  till  the  surface  begins  to  whiten,  then  de-ionized  by 
means  of  alcohol,  applied  once  in  two  or  three  weeks,  is  an  excellent 
local  stimulant.]  Vesication  or  blistering,  more  particularly  by 
means  of  a  liquid  vesicant  painted  on  with  a  brush,  may  serve  to 
whip  up  the  pilary  growths,  as  it  were.  Physical  stimulants  may 
also  be  employed,  such  as  faradization,  high  frequency  currents,  etc. 
I  have  witnessed  in  my  laboratory,  in  cases  of  alopecia  decalvans,  a 
remarkable  re-growth  under  the  influence  of  radiotherapy,  strictly 
limited  to  the  stimulated  regions;  of  course  the  .r-rays  must  be 
employed  in  lower  dosages  than  those  which  cause  epilation  (2  to  3 
units  H  every  fifteen  or  twenty  days).  Numerous  authors  have 
recently  recommended  the  employment  of  ultra-violet  rays. 

Salves  and  plasters  which  are  sometimes  given  to  these  patients 
possess  no  special  virtues. 

The  condition  of  the  scalp  should  be  attended  to  as  a  whole,  treat- 
ing pityriasis,  seborrhea,  or  concomitant  lesions  if  present. 

In  order  to  facilitate  the  local  treatment  in  cases  with  extensive 
or  numerous  areas,  it  is  advisable  to  cut  off  or  shave  the  remaining 
hair.-  In  this  case  a  wig  will  have  to  be  worn,  if  the  patient  desires 
to  conceal  his  condition.  When  the  patches  are  not  very  extensive, 
they  can  be  hidden  more  or  less  effectually  by  touching  them  up 
with  burned  cork. 

DYSTROPHIC  TRICHOSES. 

Leukotrichia  and  Canities. — Congenital  absence  of  pigment  in 
the  hairs  is  known  as  leukotrichia.  It  is  generalized  and  accom- 
panied by  a  lanugo-like  atrophy  in  albinism,  which  is  very  rare,  or 
it  may  be  partial,  limited  to  a  tuft  of  hair,  as  occurs  hereditarily  in 
certain  families. 

Canities  is  an  acquired  achromia;  the  hairs  on  the  scalp  and  body 
turn  grayish,  then  gray  and  finally  entirely  white.  It  is  'physiological 
aficr  a  certain  age,  but  very  variable  according  to  races,  families, 
individuals  and  mode  of  life;  so  that  in  a  given  case  it  can  be  desig- 
nated as  senile  or  as  premature.  Its  distribution  and  relative  develop- 
ment on  the  scalp,  the  beard  and  the  other  hairy  regions  are  so  vari- 


DYSTROPHIC  TRW  HOSES  417 

able  that  no  summary  account  is  possible  and  all  that  can  be  said  is 
that  the  condition  is  essentially  diffuse  and  progressive. 

Pathological  canities,  more  or  less  extensive  and  diffuse,  is  seen  in 
the  course  of  several  nervous  diseases  and  of  cachexia. 

Numerous  cases  have  been  quoted  in  which  canities  is  said  to 
have  developed  suddenly,  in  a  single  night,  for  instance,  under  the 
influence  of  extreme  terror;  Dr.  Parry  is  said  to  have  seen  the  hairs 
of  a  sepoy  who  had  been  tied  to  the  muzzle  of  a  cannon  whiten  in 
half  an  hour.  This  is  highly  improbable.  I  do  not  know  of  any 
observation  on  sudden  canities  in  the  course  of  the  last  four  years, 
which  have  certainly  been  prolific  of  unspeakable  horrors. 

Sometimes,  a  partial  canities  which  may  be  temporary,  follows 
after  baldness  due  to  alopecia  areata,  erysipelas,  and  so  forth. 

The  mechanism  of  the  decoloration  is  unknown.  The  hairs  very 
rarely  whiten,  gradually  beginning  at  the  root  or  at  the  free  end. 
Cases  of  ringed  canities  [pili  annulati]  have  been  reported,  with 
alternately  white  and  colored  segments.  As  a  rule,  the  blanching 
is  total,  progressive  and  more  or  less  rapid  for  a  given  hair. 

The  penetration  of  air  between  the  cells  of  the  hairs  does  not 
sufficiently  explain  the  whiteness;  there  is  not  only  failure  of  pro- 
duction but  actual  destruction  of  the  pigment,  either  through  special 
pigmentophagous  phagocytes,  as  claimed  by  Metchnikoff,  or  more 
probably  through  consumption  of  the  pigment  in  situ. 

The  treatment  of  canities  is  practically  illusory.  The  role  of 
internal  medication  and  hygiene  is  limited  to  raising  the  general 
nutritional  standard.  Stimulating  applications,  heating  the  scalp 
according  to  some,  or  epilation  of  the  first  white  hairs  may  at  the 
onset  delay  the  appearance  of  canities. 

Actually,  the  only  corrective  agent  which  certain  individuals  are 
obliged  to  employ  for  business  reasons,  consists  in  the  use  of  hair- 
dyes.  With  the  exception  of  burned  cork,  or  henna  which  gives  a 
red  or  blond  color  or  a  brownish  tint,  according  to  its  mode  of 
application  and  hydrogen  peroxide  which  reddens  and  bleaches  the 
still  pigmented  hairs,  all  dyes  may  be  injurious;  several  are  positively 
dangerous,  more  particularly  those  containing  paraphenylendiamin. 
The  least  harmful  are  perhaps  the  silver  nitrate  and  pyrogallic  acid 
preparations.  Numerous  formulas  may  be  found  in  special  works 
on  this  subject. 

Trichorrhexis  Nodosa. — Under  this  name  is  designated  a  very 
common  affection  of  the  beard  in  men  and  of  the  scalp  and  pubic 
hairs  in  women,  characterized  by  a  localized  splitting  of  the  hair, 
the  fibers  becoming  separated  in  the  form  of  two  brooms  pushed 
into  each  other. 

This  results  in  the  appearance  of  white  nodosities,  at  the  level  of 
which  the  hair  bends  and  is  easily  broken  off.  These  thickenings  are 
27 


418 


TRICHOSES 


numerous,  especially  toward  the  free  end  and  lead  to  shortening  of 
the  scalp  or  body  hairs. 

This  affection  was  considered  for  a  long  time  as  parasitic  and 
contagious.  Sabouraud,  who  found  it  in  nearly  all  the  old  shaving 
brushes  examined  by  him,  showed  it  to  be  traumatic  and  due  to  an 
excessive  withdrawal  of  oil  through  abuse  of  soapy  washes  and 
lotions.  The  remedy  is  therefore  to  cut  the  hairs  below  the  fractures 
and  to  keep  them  constantly  oiled. 

Trichoptilosis. — Trichoptilosis  is  a  cleavage  in  the  longitudinal 
direction  of  the  hairs  on  the  scalp  or  of  long  beard-hairs,  which 
become  forked  at  their  extremity.  Severe  chronic  diseases  or  con- 
stitutional weakness  may  perhaps  act  as  predisposing  factors 
although  it  is  also  observed  in  perfectly  healthy  individuals.  The 
disease  seems  to  depend  upon  an  exaggerated  dryness  of  the  hair. 
The  treatment  is  that  of  trichorrhexis. 


Fig.  130. — Monilethrix,  showing  the  scalp  and  the  parotid  and  palpebral  regions  in  a 
child  aged  nine  years. 


Monilethrix  or  Aplasia  Moniliformis.  This  is  a  rare,  familial 
and  hereditary  congenital  dystrophy,  related  to  keratosis  pilaris  and 
ichthyosis  (Fig.  L30). 

It  consists  of  a  peculiar  conformation  of  the  hairs  which  are  alter- 
nately and  regularly  constricted  and  swollen,  spindle-shaped,  dry, 
shrivelled,  brittle  and  usually  very  short:  the  fractures  occur  at  the 


PARASITIC  TRIC HOSES 


419 


level  of  the  constrictions;  the  thicker  portions  are  more  pigmented 
(Fig.  131). 

One  is  inclined  to  admit  that  the  formative  hair-papilla  under- 
goes changes  of  dilatation  and  atrophy,  comparable  to  a  pluri- 
diurnal  rhythmic  pulsation.  The  follicles  usually  present  the  lesions 
of  keratosis  pilaris  and  often  form  an  acuminate  elevation  which 
may  ultimately  become  replaced  by  a  minute  cicatrix.  The  scalp 
is  especially  affected  and  generally  appears  entirely  denuded. 
Hallopeau  showed  that  the  pilary  system  of  the  entire  body  may 
be  involved.  Sometimes  this  dystrophy  slightly  subsides  with 
advancing  age. 

The  treatment  is  that  of  keratosis  pilaris. 


Fig.   131.— Monilethrix. 


PARASITIC  TRICHOSES. 

There  are  two  kinds  of  parasitic  diseases  of  the  scalp-  and  body- 
hairs:  (1)  the  tineas,  in  which  the  parasites  reach  the  hair  at  its  root 
and  invade  the  follicle  as  well  as  the  surface-epidermis;  (2)  the 
trichomycosis,  in  which  only  the  shaft  of  the  hairs  is  affected. 

Tineas. — The  name  of  tineas  must  be  reserved  at  the  present 
day  for  a  group  of  parasitic  dermatoses  of  the  hairy  scalp  due  to 
fungi.    They  are  extremely  interesting  not  only  for  dermatologists 


420  TRICHOSES 

but  for  all  physicians,  representing  very  insidious  diseases,  some- 
times hard  to  recognize,  of  proverbial  tenacity,  difficult  to  treat 
and,  moreover,  highly  contagious.  They  have,  accordingly,  a  social 
importance. 

The  tineas  are  three  in  number:  Tinea  favosa  (favus),  tinea 
microsporica  and  tinea  trichophytica.  The  last  two  may  be  com- 
bined under  the  name  of  tinea  tonsurans.  The  general  discussion  of 
their  parasites  will  be  found  in  the  chapter  on  parasitic  dermatoses 
(Chapter  XXV). 

Children  alone  are  liable  to  contract  tineas,  the  reason  for  this 
privilege  being  unknown;  it  must  be  assumed  that  in  them  the 
chemical  constitution  of  the  scalp  differs  from  what  it  will  be  after 
puberty.  Aside  from  the  matter  of  age,  there  exist  no  conditions 
of  immunity.  All  tineas  result  from  contagion,  either  direct  by 
contact  or  more  generally  indirect  by  mediation  of  toilet  articles, 
combs,  brushes,  clippers,  scissors,  towels,  hats,  etc.  Transmission 
between  children  of  the  same  family  is  extremely  common.  Real 
epidemics  may  be  observed  in  schools  or  gatherings  of  children 
where  an  unrecognized  tinea-carrier  has  been  admitted. 

With  these  remarks  on  the  general  etiology,  each  tinea  will  now 
be  discussed  separately. 

Tinea  Favosa  [Favus]. — The  hairy  scalp  is  the  seat  of  predilection 
of  favus.  At  the  onset,  the  achorion  vegetates  on  the  surface,  only 
in  the  horny  layer,  where  it  causes  red  and  scaly  spots;  this  stage 
usually  passes  undetected. 

In  the  fully  developed  stage,  the  most  typical  clinical  form  is  that 
known  as  favus  scutularis,  the  "favus  a  godets"  (favus  with  cups); 
it  is  described  as  favus  urceolaris  when  the  scutula  are  discrete, 
regular,  centered  by  a  hair  and  of  a  bright  sulphur-yellow  color; 
favus  squarrosus,  when  they  are  confluent,  misshapen  and  con- 
glomerated in  grayish,  powdery,  scaly  crusts  held  together  by 
dried  pus. 

The  spots  or  patches  of  favus  are  of  very  variable  extent,  some- 
times larger  than  the  palm  of  the  hand.  The  entire  scalp  may  be 
invaded  except  a  border  about  1  cm.  in  width  which  curiously 
enough  always  remains  free. 

On  removing  the  cups  (p.  51G)  with  a  curette,  there  is  found  below 
either  a  smooth  depression  or  a  suppurating  ulcer  or  at  any  rate  a 
subacute  dermic  inflammation  with  a  tendency  to  cicatrization.  In 
long-standing  patches  of  favus,  cups  and  crusts  are  accordingly  seen 
intermingled  with  smooth,  pinkish  cicatrices  of  irregular  shape. 

On  the  favus  patches  the  hairs  have  in  part  disappeared;  those 
which  persist  emerge  in  tufts  from  the  interstices  of  the  crusts.  They 
are  dull,  discolored,  resembling  tow.  They  do  not  break  easily  but 
yield  readily  to  traction,  with  their  root  surrounded  by  its  swollen, 


PARASITIC  TRICHOSES  42] 

inoist,  white  or  hyaline  epithelial  sheath.  The  microscope  readily 
reveals  the  mycelium  in  the  hairs  at  least  in  the  first  portion  of  their 
length. 

The  hairs  which  have  fallen  out  are  not  replaced.  Favus  of  the 
scalp  leads  more  or  less  rapidly  to  cicatricial  alopecia,  arranged  in 
spots  or  networks,  characterized  by  its  smooth,  shining,  more  or  less 
reddened  and  sharply  outlined  surface;  here  and  there,  crinkled 
hairs  of  normal  thickness  and  length  persist  isolated  or  in  small 
groups. 

In  other  cases  the  cups  are  not  apparent  and  it  is  the  dull  and 
grayish  appearance  of  the  hairs  emerging  from  the  affected  regions 
which  indicates  the  condition  present. 

The  pityriasic  form  of  favus  manifests  itself  as  distinctly  outlined 
spots,  covered  with  dry  gray  scales;  the  microscopic  examination  of 
the  scanty  and  lustreless  hairs  establishes  the  differential  diagnosis 
from  psoriasis  or  eczema. 

In  the  impetiginous  form  of  favus,  crusts  especially  are  seen, 
gluing  the  hairs  together  and  affording  a  lodging  for  pediculi.  There 
is  always  a  history  of  the  lesion  dating  back  several  years. 

Removal  of  the  crusts  exposes  a  pinkish  bald  surface ;  after  some 
time,  scutula  appear,  pierced  by  lustreless  hairs  infiltrated  with 
mycelium. 

The  alopecic  form  very  closely  suggests  pseudo-favic  alopecia. 
There  are  no  crusts  or  scales,  but  spots  or  islands  of  cicatricial 
alopecia;  at  their  circumference  are  seen  slightly  papular  folli- 
culitides;  a  microscopic  examination  of  the  emerging  hairs  is  neces- 
sary to  establish  the  differential  diagnosis  from  acne  decalvans. 

Tinea  Microsporica. — Tinea  tonsurans  with  small  spores — or  tinea 
of  Gruby-Sabouraud — is  frequent  in  children  from  four  to  ten 
years,  especially  in  boys;  it  is  extremely  contagious.  When  left 
untreated,  it  disappears  spontaneously  at  about  the  age  of  fifteen 
years. 

It  may  be  recognized  from  a  distance  as  round  or  oval,  large  or 
medium-sized,  distinctly  outlined  patches  of  a  dusty  appearance, 
covered  with  gray  foliated  scales,  whence  emerge  only  a  few  healthy 
hairs  nearly  all  being  broken  off  short,  of  a  length  of  about  3  to  5 
mm.,  lustreless  and  of  an  ashen  gray  color,  all  inclined  in  the  same 
direction  (Fig.  132). 

It  is  seldom  that  only  a  single  patch  is  present;  generally  from 
four  to  ten  can  be  counted. 

The  most  recent  patches  are  lenticular  or  nummular  in  size;  the 
oldest  may  measure  5  to  6  cm.  in  diameter  or  more.  The  condition 
has  therefore  been  described  as  having  large  patches  but  small 
spores.  Diseased  hairs  scattered  outside  of  the  patches  can  never 
be  demonstrated.    But  the  hairy  scalp  may  be  involved  as  a  whole. 


!_'•_' 


TRICHOSES 


( )n  grasping  the  hairs  of  a  patch  of  microsporia  tinea  between  the 
nails  of  the  thumb  and  index  finger,  or  between  the  blades  of  a  pair 
of  forceps,  a  certain  number  can  be  easily  pulled  out  without  pain, 
for  they  break  oil'  a  short  distance  below  the  epidermic  surface. 

Viewed  with  a  lens  these  hairs  are  seen  to  be  surrounded  by  a 
dull  white  sheath  for  a  distance  of  1  or  ."»  nun.  Microscopical 
examination,  after  the  action  of  40  per  cent,  caustic  potash  solu- 
tion, shows  this  sheath  to  be  formed  by  a  thick  and  regular  layer  of 
round   or  polyhedral,   somewhat    uneven    spores,   measuring  from 


132. — Tinea  tonsurans  m 


jrosporica.     The  cultures  yielded  niicrosporon 
lanosum. 


2  to  4  ji  in  diameter;  the  hair  thus  resembles  a  rod  dipped  in  glue 
and  then  rolled  in  fine  sand.  The  spores  do  not  generally  seem 
to  be  accompanied  by  mycelic  threads,  are  not  arranged  in  short 
chains  and  are  evidently  ectothrix  [outside  the  hair-shaft]  (Fig.  L33). 

Careful  inspection  of  the  hair  after  it  has  been  freed  from  its 
sheath  of  niosaie-likc  spores,  may  nevertheless  reveal  delicate 
mycelic  filaments,  with  widely  separated  septa,  dividing  from  above 
downward  dichotonously,  with  superficially  emerging  brandies, 
which  perhaps  give  rise  to  the  spores.  At  the  lower  portion  of  the 
microsporic  hair  broken  off  near  its  bulb,  numerous  mycelic  threads 
can  sometimes  be  seen,  constituting  what  is  known  as  "Adamson's 
fringe." 

The  presence  of  friable  hairs  clinically  differentiates  the  small- 


PARASITIC  TRICHOSES 


423 


Fig.  133.— Radicular  portion  of  a  hair  in  tinea  microsporica  (microsporon  lanosum.) 
B  and  C,  microsporon  sheath;  at  A  the  subjacent  threads  of  mycelium  are  shown; 
D,  mycelic  fringe  of  Adamson;  E,  epidermic  cells  of  the  cuticle  or  of  the  follicle.  After 
Sabouraud.     X  260. 


424  TRICHOSES 

spored  tinea  tonsurans  from  pityriasis  capitis,  which  moreover  is 
generally  diffuse;  from  psoriasis  of  the  seal])  and  from  the  form  of 
dry  eczema  named  tinea  amiantacea  by  Alibert.  In  these  various 
affections,  on  the  contrary,  the  length  of  the  hairs  is  preserved,  they 
are  solid  and  fall  out  as  a  whole  without  breaking.  The  differences 
between  the  small-spored  tinea  tonsurans  and  trichophytosis  of  the 
hairy  seal])  will  appear  from  the  following: 

Tinea  Trichophytic  a. — Trichophytic  tinea  tonsurans  —  or  tinea 
with  large  spores — likewise  affects  children  exclusively;  but  it  may 
be  prolonged  until  about  the  twentieth  year  or  exceptionally 
later.  It  is  actually  twice  as  common  in  Paris  as  the  small-spored 
tinea,  especially  among  girls.  In  contradistinction  to  the  latter,  it 
manifests  itself  as  small  patches,  scattered  in  large  numbers,  or 
rather  as  numerous  dots,  each  made  up  of  a  few  diseased  hairs; 
these  dots  become  fused  and  may  form  larger  patches,  of  any  shape, 
but  a  large  number  of  healthy  hairs  which  hide  the  diseased  hairs 
usually  persist.  This  tinea  has  therefore  much  less  striking  symp- 
toms and  may  escape  an  inexperienced  observer. 

A  distinction  must  be  made  between  two  principal  varieties,  two 
clinical  types,  depending  upon  different  trichophytic  species.  Their 
distinctive  features  are  as  follows,  according  to  the  description  of 
Sabouraud : 

1.  The  diseased  hairs,  intermingled  with  numerous  healthy  long 
hairs,  may  be  gray,  broken  off  at  a  height  of  2  to  4  mm.,  bent  in  all 
directions,  bristling  as  it  were;  the  epidermic  surface  is  covered  wTith 
dry  or  greasy,  rather  thick  scales,  containing  twisted  infected  hairs ; 
this  form  constitutes  trichophyton  with  crateriform  growth  [in  cultures; 
briefly  T.  erateriforme]. 

2.  In  the  other  variety,  the  diseased  patches  between  the  surviving 
hairs  are  dotted  with  black  points  resembling  powder  grains  and 
sometimes  with  follicular  elevations  analogous  to  those  of  keratosis 
pilaris;  no  diseased  hairs  protrude;  they  are  enclosed  in  the  horny 
layer,  broken  off  flush  with  the  surface  or  twisted  on  themselves  in 
the  follicular  ostium.  These  are  cases  of  trichophyton  with  acuminate 
growth  [T.  acuminatum]. 

The  hairs  for  microscopic  examination  must  not  be  taken  hap- 
hazard or  pulled  out  with  the  fingers,  for  the  tinea  wrould  then 
remain  unrecognized.  Remnants  of  hairs  must  be  looked  for  and 
extracted  with  fine  pincers  or  with  a  needle.  These  diseased  hairs 
will  be  found  to  be  packed  with  spores  larger  than  those  of  micro- 
sporon  and  lodged  in  the  substance  of  the  hair  itself;  these  tricho- 
phytons therefore  are  endothrix  (Fig.  134). 

If  the  spores  are  square,  lie  in  tiers  or  bands  with  resistant  [co- 
herent] mycelium,  the  case  is  one  of  trichophyton  erateriforme.  If 
the  spores  are  rounded  or  oval,  easily  separated,  the  myecelium 


PARASITIC  TRICHOSES 


425 


brittle  and  the  hair  resembles  a  bag  of  nuts,  the  case  is  one  of 
trichophyton  acuminatum. 

According  to  the  investigations  of  Sabouraud  (1908),  this  micro- 
scopical difference  is  not  absolute,  however,  and  cultures  are  required 
for  the  differentiation  of  the  two  species. 

Tinea  trichophytica  is  more  often  overlooked  than  confused  with 
other  affections.  Not  infrequently  it  is  a  patch  of  herpes  circinatvs 
occurring  [on  the  glabrous  surface]  on  the  little  patient  or  some  one 
in  his  invironment  that  first  attracts  attention;  or  there  may  be  a 
diffuse  alopecia  accompanied  by  a  slight  scaling  on  the  scalp. 


Fig.  134. — Hair  in  trichophytic  tinea,  trichophyton  crateriformis.    Threads  composed 
of  quadrangular  segments  forming  bands  of  mycelium.  After  Sabouraud.    X  260. 


Every  pityriasis  with  multiple  spots  and  all  dry  eczemas  localized 
on  the  scalp  of  children,  require  a  minute  and  painstaking  search 
for  hairs  broken  off  or  enclosed  in  the  epidermis  and  such  will  very 
often  be  found  provided  one  knows  how  to  look  for  them. 

It  is  superfluous  to  emphasize  that  the  broken  hairs  of  alopecia 
areata  which  are  dry,  clubbed,  thinned  at  their  base  and  can  be 
extracted  without  breaking,  in  no  way  resemble  the  hairs  in  tinea. 


426  TRICHOSES 

Treatment  of  the  Tineas. — No  general  treatment  is  required,  but 
these  patients  recover  more  promptly  when  their  general  condition 
is  improved  and  when  they  are  placed  under  excellent  hygienic 
conditions,  in  the  country,  at  the  seaside,  etc. 

The  prophylaxis  necessitates  immediate  strict  isolation  of  the 
patient,  especially  from  other  children. 

Favus-carriers  are  dangerous  for  everybody;  children  suffering 
from  the  microsporic  and  trichophytic  forms  can  transmit  to  adults 
only  a  readily  curable  herpes  circinatns.  All  tinea  patients,  even 
when  collected  in  a  special  school  reserved  for  them,  like  the  school 
of  the  St.  Louis  Hospital  in  Paris,  must  keep  the  head  constantly 
covered  and  be  regularly  cared  for. 

In  treating  a  case  of  tinea,  it  is  indispensable  to  begin  by  cutting 
the  hair  short  with  scissors,  repeating  this  every  eight  or  ten  days. 
The  next  indications  are  to  outline  all  the  diseased  points,  to  remove 
or  destroy  the  parasites  by  appropriate  measures  and  to  preserve 
the  healthy  portions. 

In  a  case  of  tinea  tonsurans,  after  the  scalp  has  been  washed  with 
soap,  it  is  advantageous  to  paint  it  all  over  with  tincture  of  iodin 
diluted  with  three  parts  of  alcohol;  this  serves  to  bring  out  the 
affected  regions  and  protects  the  healthy  parts  from  auto-infection. 
These  soapy  washes  and  iodin  applications  may  be  repeated  every 
day  or  every  other  day. 

Where  a  radiotherapeutic  apparatus  is  available,  epilation  by  the 
.r-rays  which  evacuates  the  entire  contents  of  the  follicles  is  the 
method  of  choice.  As  shown  by  Sabouraud,  tineas  are  curable  in  a 
relatively  short  time  by  this  method — from  four  to  six  months,  for 
example,  instead  of  two  or  three  years  consumed  in  the  old  methods. 
All  the  spots  are  successively  exposed  to  the  rays,  administering  the 
necessary  doses,  namely  5  units  H.  in  one  session.  When  the  spots 
are  very  numerous  and  scattered,  it  is  necessary  to  treat  the  entire 
seal]),  which  requires  twelve  applications,  in  one  or  two  days.  Great 
care  must  be  taken  in  outlining  the  exposed  territories,  so  that  no 
strip  of  skin  either  escapes  or  receives  a  double  dose.  The  employ- 
ment of  the  method  therefore  requires  a  perfect  apparatus,  wide 
experience  and  great  care.  Between  the  fifteenth  and  twentieth  day, 
all  the  hairs  together  writh  their  roots  are  cast  off;  by  the  thirtieth 
day,  neither  hairs  nor  parasites  are  left  and  the  child  is  no  longer 
contagious.  The  re-growth  of  hair  begins  at  the  end  of  two  and  a 
half  months  and  is  complete  five  months  after  the  session;  it  goes 
without  saying  that  during  this  period  the  children  must  be  care- 
fully watched.  [It  is  advisable  to  paint  the  scalp  with  the  dilute 
tincture  of  iodin  once  a  week  for  several  weeks  after  the  raying.] 

When  radiotherapy  is  not  available,  a  strip  8  mm.  in  width 
must  be  epilated  with  forceps  around  each  patch,  in  order  to  estab- 


PARASITIC  TR1CH0SES  427 

lish  a  safety  zone;  and  then,  as  well  as  possible,  the  patches  them- 
selves, where  the  hairs  are  unfortunately  brittle;  these  epilations 
to  be  repeated  every  ten  or  fifteen  days.  Furthermore  the  spots 
should  be  painted  every  day  with  iodin  tincture  diluted  to  one-fourth 
strength;  they  should  be  dressed  with  iodized  vaselin  or  with  a 
chrysarobin  salve;  occlusion  should  be  maintained  by  means  of 
zinc  gelatin  or  strips  of  adhesive  plaster.  It  has  also  been  recom- 
mended to  rub  the  spots  every  fifteen  days  with  a  pencil  of  croton 
oil  contained  in  cocoa-butter.  The  last  named  topical  agent  gives 
rise  to  folliculitis  with  expulsion  of  the  infected  hairs,  but  is  liable 
to  leave  cicatrices;  its  action  must  be  closely  watched  and  the 
inflammation  quieted  with  moist  dressings.  The  treatment  is  con- 
tinued in  this  way  until  a  cure  seems  to  have  been  accomplished. 

Without  radiotherapy,  a  properly  treated  small-spore  tinea 
tonsurans  lasts  about  eighteen  months;  many  cases  are  prolonged 
for  two  or  four  years.  This  tinea  finally  always  gets  well  without 
cicatrices,  unless  these  have  been  caused  by  the  treatment. 

The  prognosis  of  trichophytic  tinea  is  aggravated  by  the  multi- 
plicity of  the  affected  points  and  the  difficulty  of  discovering  them ; 
moreover,  it  does  not  disappear  spontaneously  until  the  age  of 
eighteen  to  twenty  years.  By  means  of  correct  treatment,  a  cure 
can  be  obtained  in  less  than  one  year.  It  often  happens,  especially 
in  the  trichophytoses,  that  two  or  three  follicles  resist  almost  indefi- 
nitely; one  is  justified  in  destroying  these  by  electrolysis,  by  the 
thermocautery,  or  by  the  application  of  a  small  droplet  of  croton 
oil,  introduced  with  a  needle.  Many  microscopical  examinations, 
repeated  every  month  and  yielding  negative  results,  are  necessary 
before  the  case  can  be  pronouncd  cured. 

In  tinea  favosa  the  treatment  begins  with  the  removal  of  the 
crusts  and  cups  by  means  of  moist  dressings,  salicylated  vaselin, 
or  the  wearing  of  a  rubber  cap,  together  with  frequent  shampooing. 
When  the  scalp  is  clean,  epilation  is  performed  either  by  means  of 
the  ar-rays  or  with  forceps,  which  is  more  efficient  in  these  cases; 
this  is  repeated  every  month.  In  the  interval,  the  parts  are  painted 
daily  with  dilute  iodin  tincture  or  carbolized  glycerin.  Various 
ointments  of  sulphur,  copper  sulphate,  mercurial  salts,  etc.,  have 
also  been  recommended,  but  are  of  no  advantage. 

The  treatment  of  favus  by  epilation,  formulated  by  Bazin,  requires 
at  least  six  or  eight  months,  sometimes  over  a  year.  A  cure  can  be 
considered  as  probable  only  after  no  cup  and  no  infected  hair  has 
reappeared  for  three  months  after  the  last  epilation.  As  a  recur- 
rence is  even  then  not  excluded,  it  is  necessary  to  watch  the  patient 
during  at  least  another  six  months. 


I-JS 


TRICHOSKS 


TRICHOMYCOSES. 

These  are  parasitical  affections  of  the  hairs,  affecting  their  free 
shaft,  hut  not  the  root  or  the  follicle.    Several  varieties  are  known: 

Trichomycosis  Vulgaris  (Lepothrix  of  Wilson,  or  Trichomycosis 
PalmeUina  (Pick)  is  common  in  all  countries,  in  the  axillary  and 
genital  regions,  in  persons  who  neglect  the  demands  of  cleanliness. 
The  hairs  become  dull,  roughened,  nodular,  assume  a  yellowish  or 
reddish  color,  but  are  not  brittle;  there  is  often  a  regional  hyper- 
idrosis  and  ehromidrosis. 


Fig.    135. — Trichomycosis  vulgaris;  axillary  hairs  under  the  microscope. 


Under  the  microscope,  very  adherent  granular  concretions  are 
seen  on  the  hairs,  forming  an  irregular  sheath,  a  sort  of  rugous 
cortex  (Fig.  135)  or  nodules  at  intervals.  They  consist  of  zooglea 
of  cocci,  attached  to  erosions  of  the  cuticle  of  the  hairs  and  agglom- 
erated in  a  very  hard  layer.  Colombini  successfully  cultivated  and 
inoculated  this  parasite. 

There  exist  tropical  varieties,  such  as  that  studied  in  Ceylon  by 
Castellani  (1912),  due  to  Nocardia  tenuis. 

Washing  with  soap  and  antiseptic  lotions  or  ointments  suffices  for 
the  treatment;  shaving  of  the  hairs  is  only  exceptionally  required. 

Piedra  ( Trichosporosis  Nodularis  Tropicalis)  gives  rise  to  nodes 
in  the  hairs,  sometimes  of  the  beard,  arranged  without  order  and 
conveying  a  sensation  of  roughness  on  touch.  The  rounded  or 
spindle-shaped  nodules,  sometimes  of  the  form  of  a  unilateral  shell, 


PARASITIC  TRICHOSES 


429 


are  whitish,  extremely  hard  and  adherent  (Fig.  136);  they  do  not 
make  the  hairs  brittle;  Juhel-Renoy  counted  23  on  a  single  hair 
60  cm.  in  length. 


Fig.  136.- — Piedra  nodules  completely  or  partially  surrounding  the  hair. 

They  are  composed  of  fairly  large  spores,  belonging  to  one  or 
various  species  of  trichosporum,  heaped  up  and  agglutinated  under 
the  cuticle  of  the  hair.  This  affection  is  observed  in  South  America, 
especially  in  Colombia,  in  the  Balkan  Peninsula  and  exceptionally 
in  temperate  climates. 


CHAPTER   XXI. 
ONYCHOSES. 

The  nail  is  a  horny  plate  resulting  from  a  special  type  of  kera- 
tinization.  This  particular  mode  of  keratinization  is  limited  in  man 
to  the  floor  of  a  deep  depression  in  the  epidermis  of  the  dorsal 
aspect  of  the  terminal  phalanges. 

The  ungual  plate  or  nail-plate  is  of  convex  shape,  especially  in  the 
transverse  direction  and  its  root  is  inserted  into  this  depression, 
which  has  the  form  of  a  groove  or  notch.  The  root  is  bevelled  on  its 
lower  surface,  the  bevelled  edge  corresponding  to  that  portion  of 
the  invaginated  epidermis  which  secretes  the  nail  and  which  is 
known  as  the  matrix  of  the  nail  (Fig.  137). 


Fig.  137. — Nail  of  the  index  finger  of  a  newborn  infant;  longitudinal  section. 
The  middle  third  of  the  section  has  been  omitted  from  the  drawing.  A,  root;  B,  supra- 
ungual  fold;  C,  nail;  D,  subungual  groove;  E,  free  border;  F,  matrix;  G,  bed.     X  13. 


The  nail-plate  formed  in  the  matrix  grows  in  the  direction  of  the 
extremity  of  the  finger  or  the  toe.  When  it  has  pushed  forward 
from  under  the  supra-ungtial  [posterior]  fold,  the  body  of  the  nail 
rests  on  the  bed  of  the  nail  and  its  borders  are  insinuated  under  the 
lateral  (olds.  Its  extremity  is  free  and  passes  above  the  subungual 
groove. 

The  growth  of  the  nail,  which  is  about  3  nun.  monthly,  therefore 
depends  upon  the  activity  of  the  ungual  matrix.  Any  lesion  of  this 
matrix  as  a  whole  will  manifest  itself  in  an  arrest  of  growth  and  may 
be  finally  marked  by  a  transverse  ridge  on  the  ungual  plate  when  this 
lesion  has  been  temporary;  by  an  atrophy  of  the  nail  when  it  is 


CONGENITAL  MALFORMATIONS  431 

permanent.  The  partial  lesions  of  the  matrix  will  result  in  a  spot 
when  they  are  temporary,  a  streak  or  a  longitudinal  band  when  they 
are  persistent.  The  thickness  of  the  nail  seems  to  depend  upon  the 
degree  of  slanting  of  the  matrix. 

The  bed  of  the  nail  enters  to  only  a  very  slight  extent  into  the 
formation  of  the  nail  which  is  not  thicker  at  its  free  extremity  than 
at  its  root.  Nevertheless  pathological  changes  of  the  nail-bed  play 
a  certain  role  in  the  onychoses. 

The  diseases  of  the  nails,  known  as  onychias  or  onychoses,  therefore 
depend  on  pathological  changes  of  the  ungual  matrix  and  to  a  small 
extent  on  those  of  the  nail-bed;  their  inflammatory  forms  are 
designated  as  onyxis. 

It  is  customary  to  describe  with  these  onyxis  the  perionyxis, 
namely  inflammations  of  the  supra-ungual  and  lateral  folds  which 
are  clinically  hardly  separable. 

In  a  general  way,  the  onychoses  are  very  common.  They  may 
depend  on  (1)  Congenital  malformations;  (2)  local  causes,  various 
traumatisms  or  parasitic  affections  (onychomycoses);  (3)  a  locali- 
zation of  various  dermatoses;  (4)  the  effect  of  a  general  disease;  (5) 
trophoneuroses . 

These  very  different  causes  and  perhaps  also  still  others  of 
unknown  nature,  give  rise  to  equally  variable  lesions.  It  must  be 
emphasized,  however,  that  no  absolute  conformity  exists  between 
a  given  cause  and  its  apparent  effect  upon  the  nail;  identical  or 
related  causes  may  produce  very  different  symptomatic  pictures, 
while  on  the  contrary  the  same  appearance  may  result  from  a 
variety  of  causes. 

On  account  of  the  difficulty  of  biopsies  and  the  rarity  of  post- 
mortem examinations,  the  pathological  anatomy  of  the  onychoses  is 
very  imperfectly  understood. 

The  diagnosis  of  the  onychoses  is  very  often  difficult  and  may 
remain  open,  unless  the  lesion  is  a  rare  and  characteristic  one,  or  the 
nature  of  the  affection  is  elucidated  by  the  presence  of  other  cuta- 
neous localizations.  In  spite  of  the  remarkable  work  of  Heller  and 
numerous  special  contributions,  this  subject  still  remains  somewhat 
obscure. 

Congenital  Malformations. — These  may  consist,  on  both  extremi- 
ties, in  the  complete  absence  of  one  or  several  nails  {anonychia), 
sometimes  the  nails  are  replaced  by  a  horny  mass  {epidermic  nail) ; 
or  they  may  be  found  to  be  atrophic,  thin,  concave,  shovel-shaped 
{koilonychia) ;  or  they  may  be  hypertrophied  {scler onychia) ,  thick, 
blackish,  roughened,  curved  transversely,  claw-like  {onychogry- 
phosis),  or  flakey  or  longitudinally  striated,  or  wavy,  etc.  These 
malformations  are  not  uncommonly  familial,  transmitted  through 
several  generations,  sometimes  associated  with  malformations  of  the 


432 


ONYt  HOSES 


fingers,  dystrophies  of  the  hairs  or  other  hereditary  errors  of  con- 
formation, as  well  as  with  various  keratoses.  It  must  be  kept  in 
mind  that  malformations  of  hereditary  origin  like  the  nevi  some- 
times do  Dot  appear  until  advanced  childhood  or  still  later. 

Traumatic  Onychoses. — Wounds,  ecchymoses,  avulsions  of  the 
nails,  subungual  foreign  bodies,  traumatic  onyxis  and  perionyxis, 
ingrown  nail,  etc.,  belong  to  the  domain  of  surgery. 

Onychophagia,  a  bad  and  sometimes  unconscious  habit  of  gnawing 
the  nails,  is  usually  connected  with  other  stigmata  of  degeneration 
or  with  nervous  disturbances.  It  is  observed  in  children  of  both 
sexes  and  even  in  adults.  It  is  partly  referable  to  heredity,  but 
also  largely  to  imitation;  in  some  schools,  more  than  one-third  of 
the  children  bite  their  nails. 


- 

Fig.  13S. — Finger  nails  worn  down  by  scratching.     From  a  case  of  prurigo  vulgaris 
with  eczematization. 


The  gnawed  nails  no  longer  have  a  free  border;  in  the  extreme 
degree,  they  are  reduced  to  transverse  stumps,  the  pulp  of  the 
fingers  rising  up  as  a  cushion  in  front.  This  unclean  habit  may 
become  dangerous  through  the  absorption  of  pathogenic  germs 
which  have  lodged  under  the  nails.  Compulsory  measures  and 
physical  agents  are  rarely  efficient;  psychotherapeutic  treatment  is 
preferable. 

Worn-off  nails,  combined  or  not  with  various  artificial  colorations, 
arc  encountered  in  a  large  number  of  manual  occupations. 

In  chronic  pruritus  and  the  prurigos,  the  free  border  of  the  nails 
may  become  concave  and  worn,  their  surface  being  as  smooth  as  a 
mirror  (Fig.  138);  this  appearance  indicates  habitual  scratching 
to  the  dermatologist,  even  when  the  patient  is  unaware  of  the  habit 
or  wishes  to  conceal  it. 

The  popular  name  of  hang  nails  is  applied  to  small  traumatic 


ONYCHOMYCOSES  433 

tears  or  epidermal  elevations  of  the  posterior  fold  and  the  lateral 
folds;  they  easily  become  the  source  of  infections,  lymphangitis, 
etc.,  and  should  be  carefully  trimmed  [sterilized  with  iodin]  and 
covered  with  collodion. 

Onychomycoses. — The  ungual  lesions  produced  by  the  achorion 
and  the  trichophytons  (Chapter  XXV)  differ  only  by  mere  shades. 
The  diagnosis  is  based  upon  the  possible  coincidence  of  other  locali- 
zations of  favus  or  trichophytosis,  and  especially  on  the  microscopical 
examination. 

Onychomycosis  favosa  is  rare  and,  as  a  rule,  secondary  to  favus 
of  the  scalp  or  body  which  may,  however,  have  healed  while  the 
ungual  lesion  still  persists.  It  begins  in  the  subungual  grooves  or 
at  the  lateral  borders,  as  straw-colored  yellow  spots  which  are  seen 
shimmering  through  the  nail-plate;  these  spots  grow,  raise  the  nail, 
which  finally  becomes  cloudy,  thickened,  fissured,  locally  puffed  up, 
loosened  and  exfoliates.  At  last  nothing  is  left  of  it  but  roughened 
and  striated  debris.  The  growth  of  the  achorion  under  the  nail 
gives  rise  to  a  horny  substance  (Truffi);  the  nail  plate  itself  is 
invaded  secondarily;  but  according  to  Pellizari,  it  may  be  attacked 
primarily.  As  a  rule,  the  majority  of  the  finger-nails  are  involved; 
very  exceptionally  the  toe-nails. 

The  onychomycosis  trichophytica  is  generally  caused  by  trichoph- 
ytons of  animal  origin.  It  is  more  frequent  in  adults  than  in 
children  and  often  coincides  with  trichophytosis  of  the  beard  or  of 
the  hairless  skin.  Several  nails  are  generally  involved,  without 
regard  to  order.  The. lesions  begin  under  the  free  border  or  under 
the  lateral  borders  of  the  nail,  as  grayish  spots  with  irregular  or 
vague  borders,  not  so  yellow  as  in  favus.  A  beginning  at  the  root 
also  is  said  to  have  been  noted.  When  the  nail  itself  is  invaded,  its 
external  table  may  be  preserved  or  not;  in  the  former  case,  the 
nail  is  greatly  thickened,  opaque,  striated  like  rush-pith,  friable  at 
its  free  border,  concave,  or  on  the  contrary  curved  in  and  claw- 
shaped;  in  other  cases  the  external  table  is  fissured  and  worn  and 
the  nail  eroded,  spongy,  roughened,  dirty  and  more  or  less  de- 
stroyed. 

The  onychomycoses  are  painless.  They  may  undergo  a  spon- 
taneous cure,  but  when  left  untreated  usually  last  a  very  long  time, 
up  to  twenty  years  or  more;  they  are,  moreover,  very  rebellious  to 
treatment. 

In  a  general  way,  oxychomycoses  should  be  suspected  in  the 
presence  of  any  chronic  onychosis  of  obscure,  supposedly  trophic 
cause,  etc. 

Microscopical  examination  of  nail-dust,  scraped  off  and  heated 
on  a  glass  slide  in  a  40  per  cent,  potash  solution,  shows  mycelic 
elements,  which  are  shorter  and  more  irregular  in  favus  than  in 
28 


434  ONYCHOSES 

trichophytosis;  l>ut  the  distinction  is  not  easy.  Cultures  of  ungual 
trichophytons  often  fail  for  no  known  reason. 

The  medical  treatment  of  the  onychomycoses  consists  in  scraping 
as  much  as  possible  from  the  thickness  of  the  nail  and  in  having  the 
patient  wear  every  night  for  many  months  a  dressing  of  cotton  soaked 
in  Lugol's  iodin-iodide  solution,  covered  with  a  rubber  finger-stall 
which  does  not  compress  the  linger.  Various  salves  or  ointments 
containing  reducing  or  antiseptic  agents  may  also  be  employed. 

Surgical  treatment  is  more  rapid,  consisting  in  avulsion  of  the 
nails  after  local  anesthesia;  iodin-iodide  dressings  will  prevent 
re-infection  of  the  new  nail. 

Onychoses  of  the  Dermatoses. — There  exists  a  pyococci*;  onyxis, 
generally  due  to  an  association  of  staphylococci  and  streptococci;  it 
might  also  be  designated  as  impetiginous'  onyxis  (Fig.  139). 


Fig.   139. — Pyoroecic  onyxis  and'perionyxis  of  the  right  index  finger  and  the  left 
ring  finger,  of  one  year*s  standing,  in  a  girl  aged  ten  years. 

Although  attention  has  been  called  to  it,  notably  by  Sabouraud, 
it  is  not  sufficiently  known  and  is  a  frequent  occasion  of  diagnostic 
and  prognostic  errors.  It  is  encountered  especially  in  children  and 
youthful  individuals,  but  also  in  adults,  on  one  or  several  nails  of  the 
fingers  or  the  toes. 

Pyococcic  onyxis  generally  follows  upon  impetigo  and  especially 
upon  panaris  or  whitlows;  it  extends  beyond  these  conditions,  its 
duration  being  much  more  prolonged,  over  a  number  of  months. 
It  begins  as  minute  abscesses  under  the  angle  of  the  nail,  which  often 
dry  without  opening;  they  spread  from  one  place  to  another  in  the 
vicinity  in  the  nail-bed,  more  or  less  detaching  the  nail,  which  may 
itself  become  irregular,  roughened  and  brittle,  when  the  matrix  has 
been  invaded  by  the  process.    This  onyxis  is  always  accompanied  by 


ONYCHOSES  OF  THE  DERMATOSES  435 

perionyxis,  namely  redness,  swelling  and  even  pustulation  of  the 
peri-imgual  folds. 

The  treatment  consists  of  local  baths  with  Alibour  water  and 
moist  dressings;  later  on,  in  applications  of  yellow  precipitate  oint- 
ment or  various  tar  preparations.  When  properly  treated,  this 
affection  is  readily  curable. 

Eczema  of  the  nails  is  frequent,  generally  accompanied  by  eczema 
of  the  fingers  and  toes,  as  well  as  by  perionyxis.  The  lesions  are 
extremely  polymorphous.  There  may  be  detachment  of  the  nails 
with  redness  and  subungual  desquamation,  longitudinal  or  transverse 
ridges  with  thickening,  punctations,  erosions,  various  deformities, 
etc.    The  treatment  is  that  of  eczema. 

The  psoriatifarm  eczematides  and  psoriasis  give  rise  either  to 
dotted  cup-like  erosions  resembling  the  surface  of  a  thimble,  or  to 
transverse  and  longitudinal  striations,  or  to  detachment  beginning 
at  one  of  the  borders,  etc. 

A  positive  diagnosis  of  eczema  or  psoriasis  of  the  nail  cannot  be 
made  without  taking  into  account  the  concomitant  lesions,  but  it 
must  be  kept  in  mind  that  onychosis  may  precede  the  cutaneous 
manifestations  and  often  survives  them. 

The  treatment  of  psoriatic  onychosis  is  very  trying.  Pyrogallol 
or  chrysarobine  salves,  of  2.5  or  even  10  per  cent.,  may  be  employed. 
I  prefer  to  paint  the  nails  with  a  solution  of  one  of  these  agents  in 
ether  or  chloroform,  or  with  some  tarry  solution,  followed  by  cover- 
ing with  plaster  or  a  varnish.  Radiotherapy  is  sometimes  very 
efficient. 

In  pityriasis  rubra  pilaris  the  nail  is  thickened,  striated,  literally 
like  rush-pith,  lustreless  and  yellowish;  the  thickening  is  due  to 
a  very  hard  although  porous  hyperkeratosis  of  the  bed,  which 
becomes  conglomerated  with  the  ungual  plate. 

In  ordinary  alopecia  areata,  but  especially  in  the  extensive  and 
generalized  forms,  ungual  lesions  are  frequent,  consisting  of  dryness, 
white  longitudinal  striation,  punctation  (pitted  nail),  or  of  Assuring 
(onychorrhexis)  crumbling  and  indentation. 

In  the  severe  primary  erythrodermas,  the  nails  become  completely 
or  incompletely  detached  (total  or  partial  onycholysis)  and  in  the 
last-named  case,  if  a  new  nail  is  formed,  it  insinuates  itself  under 
the  remains  of  the  old  nail.  This  partition  of  the  nail  is  also  seen 
after  bruising,  in  syphilitic  onyxis,  etc. 

In  pemphigus ,  chronic,  foliaceous  and  hereditary,  and  in  the  grave 
forms  of  Duhring's  disease  (Fig.  140),  the  nails  are  usually  involved, 
although  in  very  different  ways.  The  nail  may  fall  without  becom- 
ing replaced;  in  this  case,  the  peri-ungual  folds  become  obliterated 
and  the  bed  is  perfectly  smooth ;  or  the  nail  is  detached  from  before 
backward,  or  divided,  or  atrophied,  or  even  onychogryphotic. 


43G 


ONYCHOSES 


In  psorospermosis  follicularis  [Darier's  disease],  the  nails  are  longi- 
tudinally striated,  furrowed  and  brittle. 

Chronic  radiodermatitis  as  an  occupational  disease  gives  rise  to 
severe  ungual  lesions,  consisting  of  fragmentation,  destruction, 
exfoliation,  or  even  total  atrophy. 

Onychosis  of  General  Diseases.  -All  severe  or  even  mild  pyrexias, 
eruptive  fevers,  typhoid  fever,  pneumonia,  anginas,  epididymitis, 
etc.;  severe  traumatisms  or  operations;  emotional  shock,  childbirth, 
etc.,  may  give  rise  to  a  groove  or  a  transverse  or  rather  bow-shaped 
ridge  on  the  nails.  All  the  nails  or  only  some  of  them,  especially 
the  thumbnails,  are  thus  marked  to  a  variable  degree.  [The  severe 
sea-sickness  of  an  ocean  voyage  is  capable  of  producing  this  effect 
on  the  nails.] 


J/E^/  tBL 

.  ^/%     vA 

ISM 

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fS   '      '  tPKi       9^^ 

T^k 

Fig.  140. — Lesion?  of  the  nails  in  a  severe  case  of  Duhring's  disease.  Definite  loss 
on  the  index  finger;  atrophy  on  the  ring  finger  and  little  finger;  detachment, 
onychauxis  and  onychogryphosis  on  the  thumb  and  middle  finger. 

This  groove  results  from  an  arrest  or  momentary  disturbance  of 
growth;  it  emerges  under  the  supra-ungual  fold  a  few  weeks  after 
the  cause  which  has  produced  it,  advancing  toward  the  extremity 
at  the  rate  of  growth  of  the  nail,  namely  about  3  mm.  monthly.  It 
furnishes  a  valuable  indication  to  recent  disturbances  in  the  health 
of  the  subject. 

Chronic  diseases,  infectious  or  constitutional,  may  also  interfere 
with  the  formation  of  the  nails  and  cause  atrophy,  koilonychia, 
fissuration  known  as  onychoschizis,  simple  hypertrophy  known  as 
onychauxis  or  scleronychia  and  onychogryphosis. 

Diseases  of  the  pleiiropulmonary  apparatus  give  rise  to  curva- 
ture with  enlargement  of  the  nails,  known  as  the  Hippocratic  nail. 

Syphilitic  Onyxis.  Ungual  lesions  due  to  secondary  syphilis  are 
entitled  to  special  mention  on  account  of  their  diversity  and 
importance.  The  condition  is  onyxis  with  or  without  peri-onyxis. 
Several  varieties  have  been  described  by  Fournier: 


DYSTROPHIC  ONYCHOSES  OF  NERVOUS  ORIGIN 


437 


The  nail  may  be  cracked  [scabritees  urigium]  and  brittle  at  its  free 
end;  or  detached  from  below  upward  (onychoschizis)  with  non- 
painful  redness  and  desquamation  of  the  bed  and  sometimes  loss 
of  the  nail;  or  considerably  hypertrophied  (pachyonyxis) ,  thickened, 
striated  and  blackish,  without  change  of  its  general  shape;  or 
ulcerated  (helconyxis) ;  in  the  last-named  case,  the  loss  of  substance, 
usually  oval,  crateriform  and  with  lamellar  borders,  appears  on  the 
lunula  and  exposes  the  matrix  or  the  bed  of  the  nail,  which  is  of  a 
grayish-pink  color. 

The  peri-onyxis  is  said  to  be  scaly  or  horny  when  a  squamous 
papule  forms  on  one  of  the  peri-ungual  folds;  inflammatory,  when 
it  consists  of  a  dusky  red,  very  persistent  tumefaction;  ulcerative, 
when  a  loss  of  substance  with  cut-out  borders  and  a  sanious  floor 
develops,  often  as  a  semicircle,  on  the  peri-ungual  folds.  The  extrem- 
ity of  the  finger  is  swollen  and  reddened;  the  nail  usually  falls  out. 
Several  fingers  or  toes  are  often  attacked  at  the  same  time. 


Fig.  141. — Syphilitic  onyxis.  At  the  thumb,  pachyonyxis  and  onychoschizis; 
on  the  index  finger,  a  large  deep  groove;  on  the  other  fingers,  cracked,  fissured, 
crumbling  nails.    The  syphilitic  infection  of  this  patient  was  of  ten  months'  standing. 


These  syphilitic  onyxes  and  peri-onyxes  (Fig.  141)  are  slightly 
painful,  develop  slowly  and  are  subject  to  recurrence;  they  are  apt 
to  reappear  in  the  course  of  the  tertiary  stage  and  prove  very  rebel- 
lious to  treatment.  Similar  ungual  lesions  or  more  common  ones 
are  met  with  in  congenital  syphilis. 

Dystrophic  Onychoses  and  Onychoses  of  Nervous  Origin— Many 
nervous  diseases  involve  the  nails,  notably  the  traumatic  neuroses, 
syringomyelia,  Morvan's  disease,  Raynaud's  disease,  tabes,  hemi- 
plegia, scleroderma,  etc.  Perhaps  the  general  diseases  referred  to 
above  act  through  the  mediation  of  the  nervous  system. 


438  ONYCHOSES 

The  form  of  the  lesions  is  extremely  variable:  simple  falling-out, 

atrophy,  detachment,  fragility,  deformity  thickening,  etc. 

All  kinds  of  onychoses,  the  nature  and  origin  of  which  could  not 
be  discovered,  have  commonly  been  referred  to  a  trophic  cause. 
I  yield  to  this  tendency  in  grouping  here  the  four  following  forms: 

Leuconychia.  -There  exist  two  varieties  of  this  affection:  One  is 
punctate  and  common  in  children,  youthful  individuals  and  women 
who  take  great  care  of  their  nails;  it  is  characterized  by  small  scat- 
tered or  profuse  white  spots  known  under  the  name  of fiores  unguium, 
mendacia  (gift-spots),  or  sometimes  by  linear  series  of  spots  which 
appear  toward  the  lunula  and  advance  with  the  nail.  Nervous 
disturbances,  some  intoxications,  etc.,  have  been  held  responsible; 
but  in  my  opinion  they  are  the  result  of  slight  traumatisms  of  the 
ungual  matrix. 

The  other  variety,  leukonychia  totalis,  may  be  congenital  or  even 
hereditary;  often  it  is  acquired  and  occurs  after  a  severe  disease,  or 
a  neuritis,  etc.  There  is  also  a  striated  variety,  with  alternately 
white  and  normal  transverse  bands. 

The  whiteness  of  the  nail  is  due  in  both  types  to  fine  bubbles  of 
air  which  have  become  infiltrated  between  the  probably  imperfectly 
keratinized  ungual  cells. 

The  patient  should  be  instructed  to  avoid  traumatism  of  the 
matrix  of  the  nails,  for  example,  in  the  manipulation  of  pushing  back 
the  supra-ungnal  cuticle  [and  the  use  of  the  pernicious  cuticle  knife]. 
The  nails  can  be  tinted  with  an  alcoholic  solution  of  eosin. 

Onychogryphosis. — This  name  was  given  by  Virchow  to  a 
deformity  consisting  of  a  sometimes  enormous  and  very  hard 
thickening,  with  a  change  in  the  direction  of  the  nail,  which  becomes 
raised  and  curved  on  itself.  The  onychogryphotic  nail  of  a  low 
degree  assumes  the  appearance  of  a  very  hard  grayish  or  brownish 
claw,  curved  transversely  and  from  before  backward  and  raised 
from  its  bed  by  hyperkeratosis. 

In  a  higher  degree,  the  nail  is  entirely  deformed,  convex  and 
twisted,  resembling  a  ram's  horn.  It  is  implanted  almost  vertically 
on  its  bed,  of  a  brownish  color  and  marked  at  the  same  time  by 
longitudinal  stria*  and  transverse  undulating  striae;  the  latter  indi- 
cate the  changed  direction  of  the  plane  of  the  matrix.  The  nail 
grows  slowly,  but  as  its  stony  hardness  prevents  it  from  being  cut, 
it  often  reaches  from  3  to  4  cm.  in  length  and  exceptionally  may 
attain  a  length  of  10  and  12  cm.  It  is  easily  understood  that  it 
becomes  troublesome  in  proportion  to  its  size. 

Onychogryphosis  is  observed  especially  at  the  feet,  on  the  big  toe 
and  sometimes  on  the  neighboring  toes  (Fig.  142).  It  is  less  common 
at  the  fingers,  where  I  have,  however,  seen  several  cases  of  it.  The 
pathogenesis  proposed  by  Virchow,  who  holds  pressure  from  the 


ONYCHOSCHIZIS 


439 


shoes  responsible  for  an  irritation  of  the  matrix,  is  therefore  not 
tenable.  Inflammatory  lesions  of  the  nail-bed,  which  were  demon- 
strated by  Unna,  are  perhaps  secondary.  It  seems  that  a  hyper- 
keratosis of  the  bed  with  hyperplasia  of  its  papillary  crests,  accord- 
ing to  Heller,  raises  and  straightens  the  nail,  which  then  grows 
thicker,  but  also  more  slowly.  At  any  rate,  this  ungual  dystrophy 
appears  especially  at  a  mature  or  advanced  age ;  it  is  almost  regularly 
present  on  varicose  limbs,  bearing  ulcers  or  the  seat  of  elephantiasis; 
or  it  may  coincide  with  chronic  rheumatism,  arteriosclerosis,  neuritis, 
leprosy,  etc. 

The  palliative  treatment  consists  of  scraping,  sawing,  or  tearing  off 
the  nail;  it  may  first  be  softened  by  means  of  potash  or  salicylic 
acid.  In  order  to  prevent  re-growths,  it  is  necessary  to  excise  the 
ungual  matrix. 


Fig.  142. — Onychogryphosis  of'the  first  three  toes. 


Onychorrhexis. — Dubreuilh  and  others  give  this  name  to  longi- 
tudinal striation  with  fragility  of  the  nails. 

In  pronounced  cases,  the  nail  is  lustreless,  cracked,  roughened, 
thinned  and  broken.  A  few  or  all  the  nails  may  be  involved.  Ony- 
chorrhexis may  date  from  childhood,  or  it  may  develop  as  a  sequel  of 
nervous  disturbances,  lichen  planus,  alopecia  areata,  etc.  The  nails 
may  be  painted  with  collodion  to  remedy  the  painful  cracks  and 
fissures. 

Onychoschizis. — This  term  (axtf  «u  =  to  separate)  designates  the 
detachment  of  nails  from  their  bed.  This  separation  is,  as  a  rule, 
progressive  and  more  or  less  rapid,  with  periods  of  remission  and 
exacerbations.  It  begins  under  the  free  border  and  gradually 
ascends  as  far  as  the  lunula;  a  single  finger  may  be  involved,  or 
usually  several  fingers  and  toes  are  attacked  simultaneously  or 
progressively.  Sometimes  the  separation  is  evidently  dependent 
upon  a  subungual  hyperkeratosis  with  accumulation  of  solid  or 
friable  horny  material. 


140  ONYCHOSES 

Onychoschizis,  like  onychorrhexis  and  a   considerable    number 

of  other  changes  of  the  nails,  mentioned  above,  are  undoubtedly 
not  always  of  the  same  etiology  and  significance.  Every  case  should 
be  traced  to  its  cause,  if  possible. 

General  Diagnosis  of  the  Onychoses. — Sometimes  the  objective 
features  of  ungual  lesions,  or  the  circumstances  and  coincidences 
are  such  that  they  can  be  referred  to  a  definite  cause  from  the  start. 
Not  infrequently,  however,  in  clinical  cases  the  etiology  is  neither 
apparent  nor  easily  discovered.  A  hasty  diagnosis  of  "trophic 
disturbance  of  the  nails" — as  is  only  too  frequently  made  and  merely 
amounts  to  an  admission  of  ignorance — should  be  refrained  from  in 
such  cases.  When  confronted  with  an  onychosis  of  obscure  char- 
acter, the  physician  must  pass  in  review  the  different  classes  of  lesions 
enumerated  in  this  chapter,  in  order  to  find  out  where  it  belongs. 

It  is  well  to  remember  the  following  facts:  Malformations  of  the 
nails  of  congenital  origin,  or  those  connected  with  familial  and  hered- 
itary dystrophies  may  appear  a  fairly  long  time  after  birth;  per- 
manent deformities  of  the  nails  may  result  from  traumatisms  which 
have  damaged  their  matrix;  onychomycoses  of  indefinite  duration 
may  occur  without  tinea,  sycosis  or  epidermomycosis,  and  require 
microscopic  examination;  the  onychoses  of  the  dermatoses,  pyo- 
coccia,  eczema,  eczematides,  psoriasis,  lichen  planus,  Duhring's 
disease,  etc.,  not  infrequently  persist  after  the  cutaneous  manifes- 
tations have  disappeared  and  may  exceptionally  precede  them; 
syphilis  and  congenital  syphilis  require  very  careful  investigations 
and  sero-diagnosis. 

Finally,  the  discovery  of  chronic  constitutional  diseases  (diabetes, 
etc.)  or  infectious  diseases  (tuberculosis,  etc.),  as  well  as  nervous 
diseases,  even  abortive  or  incipient,  may  sometimes  supply  diag- 
nostic indications  and  suggest  the  proper  treatment. 

A  systematic  review  of  this  kind  will  considerably  reduce  the 
number  of  cases  described  as  trophic  disturbance  of  the  nails,  or 
trophoneurotic  onychosis. 

The  treatment  must  frequently  utilize  either  keratolytic  or  reducing 
agents.  Often,  even  in  cases  of  enigmatic  character,  considerable 
benefit  is  obtained  from  high  frequency  currents  and  especially  from 
radiotherapy. 


CHAPTER  XXII. 
HIDROSES. 

The  name  hidroses  (jdptoq  =  sweat)  may  be  applied  to  func- 
tional disturbances  of  the  sweat-secretion  and  to  the  primary 
organic  lesions  of  the  sudoriparous  apparatus. 

The  sweat  glands  are  epithelial  tubes  whose  deep  or  secretory  por- 
tion is  rolled  up  as  a  glomerulus,  situated  in  the  lower  layers  of  the 
corium  or  the  upper  layers  of  the  hypoderm;  their  ascending  excret- 
ory portion,  the  so-called  siveat-duct,  passes  directly  through  the 
derma  and  twists  as  a  spiral  in  the  epidermis.  This  channel  opens 
obliquely  at  the  surface  through  a  pore.  This  arrangement  of  the 
pore  and  the  sweat-channel  and,  moreover,  the  direction  of  the  fluid 
which  passes  through  them,  oppose  the  penetration  of  dust  and 
microbes  into  the  interior,  so  that  infections  of  the  skin  rarely  occur 
by  this  route. 

The  sweat-glands  are  distributed  in  unequal  numbers  over  the 
entire  integument,  including  the  palmar  and  plantar  regions,  where 
they  are  indeed  especially  abundant.  In  the  axillary  fossae  and  in 
the  anogenital  region,  they  are  of  a  special  type,  their  secretory 
portion  here  having  a  very  large  lumen  and  serving  as  a  receptacle 
for  the  sweat. 

The  sweat  is  a  watery  fluid,  of  an  odor  varying  according  to  body 
regions,  individuals  and  races;  usually  of  an  acid  reaction  except  in 
case  of  profuse  sweating;  in  the  axillae  and  in  the  groins,  the  reaction 
is  normally  alkaline. 

The  quantity  of  sweat  excreted  in  a  given  time  varies  enormously, 
and  is  influenced  by  temperature,  exercise  or  rest,  amount  of  bever- 
ages, action  of  the  nervous  system,  as  well  as  some  -pathological 
conditions  and  medicinal  agents.  The  average  quantity  is  estimated 
at  about  a  litre  in  twenty-four  hours. 

Under  normal  conditions,  the  sweat  evaporates  in  proportion  to 
its  production.  Neither  this  insensible  perspiration  nor  profuse 
sweating  act  as  emunctories,  but  they  greatly  contribute  to  the 
regulation  of  the  body  temperature.  Another  function  of  the  sweat 
is  the  maintenance  of  a  moist  and  supple  horny  layer,  as  well 
through  its  watery  content  as  through  the  emulsified  fat  contained 
in  it. 

The  chapter  on  hidroses  is  not  of  particular  interest  to  the 
dermatologist.  A  distinction  must  be  made  between  functional  and 
organic  hidroses : 


442  HIDROSES 

1.  Disturbances  of  the  sweat  secretion,  or  junctional  hidroses, 
belong  to  a  considerable  extent  to  the  domain  of  general  medicine. 

2.  Organic  lesions  of  the  sweat-glands,  or  organic  hidroses,  are  on 
the  whole  rare. 

Among  the  latter,  hidrocystoma  and  hidradenoma  will  be  described 
with  the  tumors;  among  the  keratodermas,  in  a  preceding  chapter, 
mention  has  been  made  of  porokeratoses  or  punctuate  keratoses, 
which  are  without  sufficient  reason  interpreted  as  ostio-sndoriferons 
keratoses.  Dysidrosis  and  miliaria  likewise  have  no  definite 
relations  with  the  sweat  structures.  The  following  discussion 
will  accordingly  be  limited  to  sudamina,  hidradenitis  and  miliary 
abscesses. 

FUNCTIONAL  HIDROSES. 

The  anomaly  concerns  either  the  quantity,  or  the  odor,  or  the 
color  of  the  sweat. 

Anidrosis. — Very  exceptional  cases  have  been  reported  of  indi- 
viduals who  do  not  perspire  and  therefore  imperfectly  regulate  their 
temperature,  as  a  result  presenting  symptoms  of  heat-stroke  on 
even  moderate  exposure  to  the  sun  in  summer-time.  A  striking 
observation  of  this  kind  was  recentlv  published  by  R.  Lutenbacher 
(May,  1917). 

The  sweat  is  very  scanty  in  persons  suffering  from  diabetes, 
myxedema,  cachexia,  ichthyosis,  as  well  as  in  senile  degeneration 
of  the  skin.  Sweating  is  temporarily  absent  in  several  chronic 
erythrodermas,  on  the  patches  of  psoriasis  and  in  a  considerable 
number  of  other  eruptions. 

Hyperidrosis. — Individual  differences  in  the  amount  of  sweat 
excreted  are  such  that  hyperidrosis  is  never  more  than  relative. 

The  profuse  transpirations  which  occur  in  the  course  or  at  the 
decline  of  the  pyrexias,  sweating  or  miliary  fever,  acute  rheumatism, 
the  sudoral  form  of  typhoid  fever,  pneumonia,  grippe,  septicemias, 
etc.,  the  sweats  of  phthisis,  gout,  or  the  moribund  do  not  belong  to 
the  realm  of  this  discussion. 

In  a  considerable  number  of  organic  or  functional  nervous  diseases, 
in  hemiplegia,  tabes,  neuritides,  wounds  of  the  nerves,  lesions  of  the 
sympathetic,  neurasthenia,  exophthalmic  goitre,  etc.,  there  occur 
profuse  sweats,  generalized  or  partial,  permanent  or  in  attacks. 
This  is  suggestive  of  a  nervous  pathogenesis  in  the  so-called  essential 
hyperidroses.  Moreover,  these  are  preferably  observed  in  highly 
emotional  individuals,  or  associated  with  obesity  or  auto-intoxica- 
tion. The  sweat  may  exude  all  the  time  or,  on  the  slightest  effort 
or  trifling  emotion,  moisten  the  surface  of  the  skin,  sometimes 
flowing  in  profuse  drops.  Maceration  of  the  epidermis  in  the  folds 
is  a  common  sequel. 


FUNCTIONAL  HIDROSES  443 

Hyperidrosis  may  be  general,  or  more  frequently  partial,  when 
it  is  known  as  ephidrosis.  There  is,  for  instance,  a  total  facial  ephid- 
rosis,  or  hemifacial  or  localized  ephidrosis.  The  secretion  in  these 
patients  may  occur  as  a  reflex  under  the  influence  of  mastication 
or  certain  gustatory  sensations,  among  others  that  of  vinegar  or 
chocolate. 

It  is  a  familiar  fact  that  bald  persons  usually  transpire  freely  from 
the  scalp  and  face ;  I  believe  that  this  hyperidrosis  is  connected  with 
kerosis  and  dependent  upon  its  multiple  causes  (p.  196). 

The  sweat  of  kerotic  individuals  is  sometimes  charged  with  such 
an  abundance  of  emulsified  fluid  fat  as  to  cause  grease-spots  on 
pillows,  hats,  paper  placed  on  the  skin,  etc.  These  cases  are  desig- 
nated by  the  name  of  hyperidrosis  oleosa.  The  condition  is  probably 
a  combination  of  hyperidrosis  with  seborrhea  oleosa  (p.  393). 

The  peculiar  affection  which  bears  the  name  of  granulosis  rubra 
nasi  seems  to  be  regularly  associated  with  hyperidrosis  and  is  prob- 
ably a  result  of  the  latter.  It  is  observed  especially  in  children  and 
is  characterized  by  small  pinkish  or  red  miliary  papules  on  a  lavender 
and  cold  background;  the  lesions  occupy  the  nose  and  sometimes 
the  lips  or  the  chin;  they  become  less  marked  with  advancing  years. 

The  extremities  are  constantly  moist  or  even  wet  with  sweat  in 
some  individuals.  When  the  hands  are  affected,  a  number  of  occu- 
pations are  rendered  impossible;  at  the  feet,  the  excessive  sweat 
macerates  the  epidermis,  makes  the  skin  very  vulnerable,  markedly 
impedes  walking  and  often  becomes  offensive.  Hyperidrotic  ex- 
tremities are  rarely  warm  and  congested ;  as  a  rule,  they  are  cold, 
acro-asphyxiated  and  flabby,  or  of  a  waxy  white  color. 

Hyperidrosis  of  the  articular  folds,  especially  of  the  axillse,  is 
extremely  common;  many  obese,  gouty,  rheumatic  or  nervous 
individuals  suffer  from  this  condition.  Axillary  hyperidrosis  may 
lead  to  lepothrix  and  to  chromidrosis.  It  predisposes  to  intertrigo, 
to  deep  abscesses,  etc. 

All  dermatologists  are  familiar  with  hyperidrosis  nudorum,  a  free 
flow  of  sweat  from  the  axillae  seen  in  patients  who  are  stripped  and 
exposed  before  an  audience.  In  these  cases,  an  excretory  rather 
than  a  secretory  reflex  is  concerned ;  under  the  influence  of  cold  and 
emotion,  the  smooth  muscle  fibers  of  the  large  axillary  glands  become 
contracted  and  empty  their  contents. 

Bromidrosis. — This  name  is  applied  to  the  offensive  sweats  which 
occur  especially  at  the  feet,  sometimes  in  the  axillse  or  groins,  con- 
stituting a  most  distressing  infirmity. 

Usually,  but  not  invariably,  bromidrosis  is  connected  with  hyper- 
idrosis and  is  a  complication  of  the  latter.  It  is  possible  for  fatty 
acids  or  ammoniacal  compounds  to  become  eliminated  in  excess 
through  the  sweat,  but  as  a  rule  the  offensive  odor  is  derived  from 
secondary  decomposition. 


444  hid roses 

In  the  treatment  of  hyperidrosis  and  bromidrosis,  it  is  important 
not  to  neglect  the  correction  of  whatever  may  be  deficient  in  the 
genera]  hygiene  of  the  patients.  Locally  warm  or  lukewarm  baths 
are  recommended;  alcoholic  rubs,  for  example  with  camphorated 
alcohol,  or  with  alcohol  containing  iodin  or  tannin;  and  applications 
of  ichthyol  or  various  powders. 

<  !ases  of  offensive  sweating  of  the  feet  require  scrupulous  cleanliness, 
a  frequent  change  of  foot-wear,  the  wearing  of  shoes  permeable  to 
evaporation.  Baths,  alcoholic  rubs,  bland  powders  charged  with 
salicylic  or  tartaric  acids,  or  with  bismuth  subnitrate,  are  often 
inefficient.     Formol,  in  all  its  forms,  is  dangerous. 

A  good  treatment  of  plantar  hyperidrosis  and  bromidrosis  con- 
sists in  painting  the  parts  daily  with  a  solution  of  potassium  perman- 
ganate (1  to  10  per  1000);  or  with  iron  perchloride  solution  with 
25  per  cent,  of  glycerin. 

Still  better  results  are  obtained  by  painting  the  parts,  daily  at 
first,  then  at  longer  intervals,  with  a  solution  of  chromic  acid  (2  per 
cent.,  or  even  5  or  10  per  cent.)  followed  by  dusting  with  talcum- 
powder;  but  these  applications  must  be  very  cautiously  made. 

Against  palmar  hyperidrosis,  radiotherapy  has  been  shown  by 
Sabouraud  to  be  the  cardinal  remedy;  sometimes,  a  single  applica- 
tion of  5  units  II.  is  sufficient.  The  same  treatment  is  appropriate 
for  granulosis  rubra   nasi. 

Chromidroses.  —  The  problem  of  the  chromidroses  or  colored 
sweats,  to  which  several  publications  were  devoted  by  Le  Roy  de 
Mericourt,  still  remains  very  obscure.  Many  of  the  reported  cases 
are  doubtful  or  simulated,  but  a  few  authentic  observations  are  on 
record. 

The  colored  sweats  are  always  regional,  partial,  or  even  very 
circumscribed;  they  may  be  blue,  red,  or  black,  or  sometimes  yellow; 
green,  etc.  The  color  as  a  rule  is  the  result  of  oxidation  on  contact 
with  the  air  of  a  chromatogenic  agent  contained  in  the  sweat,  which 
then  becomes  deposited  on  the  epidermis  in  a  pulverized  form. 

A  blue  coloration  is  apparently  due  either  to  pyocyanin  and 
coexistent  with  blue  suppuration,  or  to  indican.  A  red  color  is  more 
common,  especially  in  the  axillae;  it  seems  to  be  of  microbic  origin 
and  is  frequently  associated  with  lepothrix.  Dry  erythidroses  with 
adherent  pigment  have  also  been  reported.  The  case  of  melanidrosis 
which  was  studied  by  R.  Blanchard  on  the  eye-lids  of  a  thirteen-year- 
old  boy  confirms  beyond  a  doubt  the  existence  of  this  form.  The 
black  pigment  which  he  saw  becoming  deposited  around  the  sweat- 
pores  was  examined  by  Maillard  and  found  to  be  related  to  the 
choroid  pigment. 

Hematidrosis. — It  is  conceded  that  an  oozing  of  blood  derived 
from  the  capillaries  may  take  place  on  the  intact  skin  by  way  of  the 


ORGANIC  H1DR0SES  445 

sweat  pores,  hence  the  name  which  has  been  given  to  this  phe- 
nomenon. The  majority  of  the  cases  reported  by  the  ancients,  of 
bloody  sweats  under  the  influence  of  extreme  emotional  distress,  are 
undoubtedly  mythical.  Perhaps  the  condition  actually  occurs  in 
the  course  of  severe  infections,  or  in  neuropathic  individuals,  in  the 
presence  of  purpura,  or  as  a  vicarious  menstruation.  I  am  not 
acquainted  with  any  convincing  observations. 

ORGANIC  HIDROSES. 

In  a  large  number  of  dermatoses,  the  sweat-glands  are  affected 
together  with  the  neighboring  tissues,  or  secondarily.  Primary  and 
idiopathic  affections  of  the  glomeruli  and  sweat-ducts  are  on  the 
contrary  rare. 

It  has  previously  been  stated  that  in  dysidrosis  the  sweat-glands 
play  no  part;  also,  that  miliaria  rubra  and  alba,  although  designated 
as  sudoral  eruptions  on  account  of  the  conditions  under  which  they 
are  usually  observed,  are  in  reality  a  miliary  impetigo  without  con- 
stant relation  to  the  sweat  glands  (pp.  85  and  87). 

Sudamina  [Miliaria  Crystallina]  is  the  name  applied  to  an 
affection  characterized  by  extremely  minute  bullous  elevations  of 
the  horny  layer,  containing  a  clear  watery  fluid  and  without  a  con- 
gested base. 

The  sudamina  are  the  average  size  of  a  farina  grain.  Sometimes 
they  are  scattered  in  very  variable  numbers,  sometimes  grouped  or 
even  confluent  in  small  blebs;  they  are  observed  on  the  trunk, 
notably  on  the  flanks  and  abdomen,  as  well  as  on  the  flexor  surface 
of  the  limbs.  They  appear  suddenly  without  pruritus,  altogether 
or  in  successive  crops.  Their  duration  is  ephemeral;  they  dry  out, 
the  epidermis  peels  a  little  and  all  is  well  again.  It  is  not  impossible 
for  a  few  small  vesicles  to  acquire  turbid  contents  and  a  slightly 
reddened  base,  as  the  sequel  of  a  secondary  infection  which  trans- 
forms them  into  miliary  impetigo;  but  this  is  an  exceptional 
occurrence. 

Sudamina  have  been  encountered  in  the  course  of  severe  pyrexias, 
such  as  acute  rheumatism,  typhoid  fever,  scarlatina,  at  the  crisis 
of  pneumonia,  or  as  a  phenomenon  preceding  death.  They  are  also 
observed  to  occur  under  occlusive  dressings  in  the  hot  season,  or 
in  the  course  of  treatment  with  keratoplastic  agents. 

A  sudamen,  as  shown  by  J.  Renaut,  is  a  small  bleb  situated  in  the 
horny  layer  or  immediately  below  it,  on  the  course  of  a  sudoriparous 
canal.  It  may  be  interpreted  as  the  mechanical  result  of  splitting 
of  this  layer  under  the  influence  of  a  gush  of  sweat  occurring  after  a 
temporary  anidrosis  with  stagnation  of  the  horny  layer,  or  exagger- 
ated keratinization.    The  sudaminal  contents  are  therefore  probably 


IKi  HIDROSES 

sweat,  which  by  some  authors  was  found  to  be  alkaline  or  neutral, 
by  others,  including  Jadassohn,  invariably  acid. 

No  importance,  not  even  a  prognostic  value,  can  be  attached  to 
this  trifling  lesion. 

Hidrosadenitis. — Verneuil  (1864)  described  as  phlegmonous  hidros- 
adenitis  or  sudoriparous  abscesses  an  affection  commonly  observed 
in  the  form  of  tuberous  abscesses  of  the  axilla  (Velpeau)  and  which 
according  to  him  may  also  be  localized  at  the  circumference  of  the 
anus,  at  the  external  auditory  meatus,  or  even  become  disseminated. 

This  condition  is  a  form  of  staphylococcic  pyodermatitis  which 
will  be  described  elsewhere  in  this  book.  It  is  usually  admitted  to 
result  from  an  infection  by  way  of  the  sweat-channels,  although 
this  fact  cannot  easily  be  demonstrated  directly.  [This  disease 
should  not  be  confused  with  hidradenitis  suppurativa  (Pollitzer), 
which  is  now  included  in  the  papulo-necrotic  tuberculides.] 

Miliary  Abscess  of  Little  Children. — This  condition  has  been 
known  for  a  very  long  time  and  was  already  distinguished  by 
Alibert  from  furunculosis.  It  occurs  in  neglected  or  greatly 
weakened  infants  suffering  from  impetigo,  eczema  of  the  buttocks, 
gastro-enteritis,  bronchopneumonia,  etc.,  and  consists  of  multiple 
scattered  resistant  intradermic  nodules,  all  of  about  the  size  of  a 
small  pea.  On  puncture  a  creamy  pus  is  evacuated,  their  cavity  is 
more  or  less  deeply  situated  in  the  cutis.  They  occur  in  crops,  some- 
times repeated;  the  general  phenomena  are  very  variable. 

The  pyemic  character  of  these  abscesses  was  suspected  in  the  past. 
However,  Escherich  and  Longard  surmised  and  Lewandowski  (1906) 
demonstrated  that  they  are  in  most  cases  the  result  of  a  staphylo- 
coccus aureus  infection ;  the  infection  takes  place  through  the  sweat- 
pores,  a  point  of  lessened  resistance  in  the  infantile  skin.  The  almost 
invariable  coexistence  of  small  intra-epidermic  pustules  the  size  of  a 
pin-head  has  been  demonstrated,  analogous  to  the  ostiofolliculitis 
of  Bockhardt,  but  due  to  infection  of  the  sweat-pores  and  designated 
by  Lewandowski  as  periporitis. 

As  to  treatment,  incision  of  the  abscesses  is  recommended,  next 
sweating  followed  by  sublimate  baths  of  1  per  10,000.  Zinc  sulphate 
baths  of  the  same  strength,  or  washes  with  Alibour  water,  would 
undoubtedly  prove  equally  efficient. 


PART  IT. 
NOSOLOGY  OF  THE  DERMATOSES. 


In  the  first  part  of  this  book  I  have  discussed  the  morphology  of 
the  dermatoses  with  a  comparison  of  those  related  either  by  a  com- 
mon eruptive  lesion  or  pathological  condition  of  the  skin,  or  by  a 
conformity,  of  localization  in  the  same  cutaneous  or  mucous  territory 
or  in  the  same  organic  adnexa  of  the  epidermis. 

In  the  following  part  the  dermatoses  will  be  grouped  according 
to  their  etiology,  considering  together  those  which  are  dependent 
upon  the  same  kind  of  causes. 


CHAPTER   XXIII. 
ARTIFICIAL  DERMATITIDES. 

Inflammations  of  the  skin  resulting  from  the  injurious  action 
of  a  mechanical,  physical,  or  chemical  cause  are  called  artificial 
dermatitides. 

Their  clinical  features  are  extremely  variable;  they  may  assume 
practically  all  the  forms  of  dermatological  lesions,  especially  those 
of  erythema,  urticaria,  purpura,  eczema,  blebs,  gangrene,  etc. 

The  severity  of  the  lesions,  their  superficial  or  deep  character, 
their  more  or  less  rapid  or  slow  onset,  their  ephemeral  or  prolonged 
duration,  depend  in  part  upon  the  cause  and  in  part  upon  the  soil 
on  which  it  has  acted.  The  cause  may  in  itself  be  more  or  less 
markedly  injurious;  its  action  may  have  been  more  or  less  intense  or 
persistent.  The  soil,  namely  the  damaged  skin,  in  its  turn  presents 
variations  in  vulnerability  and  capacity  of  reaction  according  to  the 
patient  and  the  region  of  the  body. 

Those  relatively  rare  cases  must  be  separately  classified  in  which 
there  exists  what  Brocq  calls  (July,  1915)  a  diminished  resistance  of 
the  skin,  which  may  be  congenital  or  regional;  this  abnormal  vul- 


Ms  ARTIFICIAL  DERMATITIDES 

nerability — which  is  the  basis  of  congenital  pemphigus,  hydroa 
vacciniforme  and  xeroderma  pigmentosum,  but  which  I  have 
observed  also  outside  of  these  affections — often  manifests  itself  only 
toward  a  certain  class  of  injurious  agents  (traumatism,  light,  etc.  I. 

In  normal  individuals,  it  may  be  stated  that  the  influence  of  the 
patient's  individuality,  his  persona]  equation,  what  is  known  as  the 
morbid  predisposition,  is  relatively  slight  in  the  case  of  most  dermat- 
itides  of  mechanical  and  physical  origin;  whereas  this  predisposition 
plays  on  the  contrary  a  leading  part  in  the  pathogenesis  of  dermat- 
itides  'of  chemical  origin,  or  toxidermas.  It  will  be  more  fully 
considered  in  the  section  devoted  to  the  latter. 

It  must  be  understood  that  there  is  no  absolute  and  constant 
agreement  between  cause  and  effect  in  the  artificial  dermatitides. 
From  this  rule  are  derived  the  two  following  corollaries: 

The  same  injurious  agent  may  give  rise,  in  different  cases,  to 
fundamentally  dissimilar  eruptions.  The  dose,  the  avenue  of  inva- 
sion, still  other  factors  and  especially  the  individual  predisposition 
strongly  modify  the  consequences  of  the  same  cause.  In  this  way, 
to  quote  an  immediate  example,  the  absorption  of  an  iodide  may 
give  rise,  in  different  cases,  to  erythema,  urticaria,  purpura,  bulla?, 
pustules,  etc. 

Inversely,  dermatitis  of  identical  appearance  may  be  derived 
from  entirely  different  injurious  causes.  A  bullous  dermatitis,  for 
instance,  may  be  the  result  of  a  burn,  the  application  of  a  blistering 
or  caustic  substance,  or  the  absorption  of  a  medicinal  agent  such  as 
an  iodide  or  antipyrin.  It  could  not  be  otherwise,  for  while  injurious 
agents  are  extremely  numerous,  the  modes  of  reaction  of  the  skin  are 
limited  in  number. 

In  dealing  with  a  given  cutaneous  lesion,  the  clinician  is  therefore 
often  puzzled  at  its  origin.  It  is  precisely  this  difficulty  which  lends 
interest  to  the  artificial  dermatitides  which  are  extremely  common. 

I  shall  successively  review  (1)  dermatitides  due  to  mechanical 
causes;  (2)  dermatitides  due  to  physical  causes;  (3)  dermatitides 
due  (or  apparently  due)  to  chemical  causes,  which  may  be  called 
toxidermas;  these  should  be  subdivided  into  two  groups,  according 
to  their  external  or  internal  origin.  It  seems  advisable  to  add  to  the 
description  of  the  latter  a  comment  on  the  autotoxic  dermatoses, 
which  although  not  artificial  may  pass  as  toxidermas. 

DERMATITIDES  DUE  TO  MECHANICAL  CAUSES. 

Traumatisms  of  all  kinds,  when  slight,  may  give  rise  to  erythema 
(Chapter  I).  More  severe  traumatisms  cause  contusions,  wounds, 
etc.,  in  short,  surgical  complications. 

The  following  belong  to  the  domain  of  dermatology:    Traumatic 


DERMATITIDES  DUE  TO  MECHANICAL  CAUSES        449 

eczema  (Chapter  IV) ;  excoriations  from  scratching  and  the  epi- 
dermic hypertrophy  known  as  lichenization;  the  latter  will  be 
discussed  in  the  chapter  on  Pruritus  (Chapter  XXIV);  certain 
traumatic  alopecias;  and  furthermore,  the  effects  of  repeated  or 
prolonged  pressure. 

Strong  and  persistent  pressure  on  some  part  of  the  skin,  like  that 
exerted  by  a  badly  fitting  plaster  apparatus,  gives  rise  at  first  to 
erythema,  then  to  phlyctinization,  finally  to  ulceration  and  even  to 
gangrene. 

Repeated  pressure  with  friction  on  a  thick  epidermis,  like  that 
produced  on  the  foot  by  hard  shoes  during  a  long  march,  or  on  the 
hand  by  the  manipulation  of  some  tool  or  instrument,  causes  the 
appearance  of  bullous  elevations  known  as  traumatic  blisters,  well 
known  to  soldiers,  mountain-climbers,  boatmen,  acrobats,  etc. 

Attention  is  here  called  to  the  special  vulnerability  of  the  skin 
which  constitutes  congenital  pemphigus  (p.  191). 

Callus. — Callus  or  callositas  represents  a  chronic  traumatic  der- 
matitis with  thickening  of  the  derma  and  hyperkeratosis.  Callosities 
are  observed  on  the  hands  of  laborers,  where  their  seat  often  betrays 
the  occupation  of  the  individual  (diggers,  gardeners,  blacksmiths, 
tailors,  etc.);  on  the  feet,  notably  on  the  instep  and  at  the  ankles; 
moreover,  on  the  prominence  of  the  head  of  the  first  metatarsal  in 
case  of  hallux  valgus,  where  they  contribute  toward  the  formation 
of  bunions;  on  the  ischial  bones  of  cavalrymen,  etc.  In  short, 
callosities  may  form  at  any  point  on  the  body. 

Callus  is  a  yellowish  or  pigmented  prominence  of  variable  extent, 
round  or  oval,  with  gently  sloping  borders,  thick  and  solid  on  palpa- 
tion. Being  a  defensive  reaction  of  the  integument,  the  callus  is  not. 
painful  either  spontaneously  or  on  pressure  unless  it  is  inflamed. 
In  this  case — the  "durillon  force"  of  Chassaignac — a  blister  may  form 
underneath  the  thickened  epidermis;  when  it  becomes  infected,  the 
subepidermic  abscess  often  gives  rise  to  lymphangitis  with  fever, 
so  that  the  patient  is  obliged  to  stay  in  bed. 

The  only  treatment  of  simple  callus  consists  in  the  suppression 
of  its  cause.  Moist  dressings  and  rest  are  the  measures  most  to  be 
recommended  in  case  of  inflammation. 

Clavus. — A  corn  or  clavus  is  a  local  traumatic  hyperkeratosis 
with  inflammation,  then  atrophy  of  the  cutis,  occurring  only  on  the 
feet,  at  points  exposed  to  chronic  pressure  from  badly  fitting  shoes. 
It  is  situated  especially  on  the  prominence  of  the  phalangeal  articu- 
lations of  the  toes,  particularly  on  the  little  toe,  or  on  the  metatarsal 
prominences  and  sometimes  on  the  sole  of  the  foot.  Its  dimensions 
vary  from  those  of  a  lentil  to  a  small  bean.  Corns  are  always  painful, 
either  spontaneously  in  damp  weather,  or  on  pressure  when  they  are 
not  trimmed. 
29 


450  ARTIFICIAL  DERMATITIDES 

Corns  differ  from  callosities  in  the  much  greater  thickness  of  their 
horny  layer  which  projects  as  a  smooth  or  scaly  prominence  and  is 
deeply  embedded  in  the  cutis;  the  latter  is  depressed  like  a  funnel 
and  inflamed  or  atrophied.  In  the  center  of  the  horny  mass  a  softer, 
white,  medullary  portion  can  often  be  distinguished,  formed  by 
poorly  keratinized  cells.  Underneath  the  corn  the  malpighian  layer 
is  thinned  and  the  papillae  are  obliterated.  Occasionally  the  center 
of  the  corn  presents  a  papilla  with  dilated  vessels  projecting  into  the 
horny  mass.  The  so-called  "root"  of  the  corn  has  no  actual  exist- 
ence and  its  extraction  by  quack  chiropodists  is  nothing  but  a  trick. 

[nterdigital  corns,  known  in  France  as  "ceil  de  perdrix"  (par- 
tridge eyes),  are  softened  as  the  result  of  maceration  [soft  corns]. 

Corns  must  not  be  confused  with  plantar  warts  or  with  mal 
perforans. 

To  be  afflicted  with  corns  may  mean  an  extremely  distressing  if 
minor  infirmity,  for  which  patients  are  apt  to  neglect  seeking  pro- 
fessional advice.  Left  untreated  and  irritated  by  pressure,  corns 
may  become  the  seat  of  an  inflammation,  a  blister,  an  abscess,  etc. 
When  badly  cut,  they  often  give  rise  to  lymphangitis. 

The  popular  treatment  consists  in  trimming  the  hyperkeratotic 
layer  with  a  razor  at  regular  intervals  before  it  again  becomes 
exuberant  and  painful,  as  well  as  in  avoiding  all  local  pressure.  The 
horny  mass  may  also  be  softened  by  nocturnal  moist  dressings,  or 
by  keratolytic  agents  such  as  salicylic  acid  plasters,  or  salicylated 
collodion,  which  permits  the  removal  of  the  corn  in  a  warm 
bath.  Without  patient  and  persistent  treatment,  a  relapse  is  very 
probable. 

DERMATITIDES  DUE  TO  PHYSICAL  CAUSES. 

Heat,  cold,  solar  and  electric  radiations,  x-rays,  beyond  a  certain 
limit,  are  injurious  to  the  human  integument.  They  give  rise  to  a 
series  of  lesions,  that  range  from  erythema  to  gangrene.  Super- 
added pyococcic  infections  frequently  complicate  the  clinical 
picture. 

Aside  from  these  general  data,  which  apply  to  all,  it  is  noteworthy 
that  especially  in  regard  to  light  radiations,  certain  individuals  are 
much  more  susceptible  than  others  (solar  erythema,  pigmentations) ; 
also,  that  there  actually  exist  special  pathological  conditions  (herpes 
vacciniformis,  xeroderma  pigmentosum)  characterized  by  dispro- 
portionate reactions  to  the  effect  of  light. 

Burns. — Burns  may  be  produced  by  burning  or  incandescent 
bodies  or  by  heated  substances,  solid,  liquid,  or  gaseous.  Lesions 
caused  by  bright  light,  electricity,  or  caustic  agents,  are  often  placed 
in  the  same  group. 


DERMATITIDES  DUE  TO  PHYSICAL  CAUSES  451 

Three  degrees  of  burns  are  recognized: 

In  the  first  degree,  the  lesions  consist  of  erythema,  with  severe  pain, 
heat,  swelling,  representing  erythema  a  calore.  In  a  few  days,  after 
desquamation,  the  skin  is  well  again. 

The  second  degree  is  characterized  by  bulla? .  These  form  either 
immediately,  the  vaporization  of  the  intramalpighian  plasma  having 
raised  the  horny  layer  under  which  a  certain  amount  of  serum 
collects;  or  secondarily,  after  a  few  hours,  through  the  mechanism 
of  superficial  or  deep  bleb-formation.  The  contents  of  the  bullae, 
which  vary  greatly  in  size,  are  lemon-yellow,  fluid  or  gelatinous. 
The  pain  is  extremely  severe.  The  bullae  having  ruptured,  the  fluid 
escapes  and  a  bright,  red,  shining  surface  appears  under  the  epidermic 
membrane;  or  they  may  shrivel  and  dry  in  crusts;  or  they  may 
become  infected  and  suppurate.  In  the  last-named  case,  a  cicatrix 
may  persist.    The  course  of  healing  lasts  one  or  two  weeks. 

In  burns  of  the  third  degree,  there  is  sloughing,  coagulation  and 
necrosis  of  the  cutis  and  sometimes  of  the  subjacent  parts.  Blisters 
appear  only  on  the  borders  of  the  slough  which  in  different  cases 
is  yellowish  or  brown,  or  dry  and  anesthetic.  The  pain  may  be  less 
severe  than  in  a  burn  of  the  second  degree,  on  account  of  destruction 
of  the  nerve-ends.  The  course,  of  very  variable  duration  according 
to  the  depth  and  extent  of  the  burn,  the  region  affected  and  the 
evactual  complications,  is  that  of  a  non-progressive  gangrene.  The 
cicatrix  is  often  vicious. 

Very  extensive  burns,  like  those  of  children  who  have  tumbled 
into  a  boiler,  or  of  soldiers  struck  by  an  incendiary  shell,  or  those 
which  I  saw  after  the  fire  of  the  Puteaux  powder  mills,  where  the 
unfortunate  women  workers  were  burned  from  head  to  foot  except 
on  the  parts  protected  by  the  corset,  are  accompanied  by  grave 
general  symptoms.  Chills,  fever  or  rather  a  lowering  of  the  central 
temperature,  collapse  or  delirium,  bloody  vomiting,  melena,  albu- 
minuria and  pulmonary  complications  are  due  in  such  cases  for  the 
most  part  to  toxic  products  resulting  from  the  alteration  of  the 
blood  in  the  cutaneous  vessels,  under  the  influence  of  heat;  in  part 
to  the  nervous  shock  and  finally  to  superadded  infections.  Burns 
involving  over  one-third  of  the  total  tegumentary  surface  are 
usually  fatal. 

The  treatment  of  burns  consists  in  cleansing  the  skin,  in  the  evacua- 
tion of  the  blisters  without  pulling  off  the  epidermis,  in  the  appli- 
cation of  sterile  occlusive  dressings.  Packing  in  aseptic  cotton, 
after  painting  with  dilute  tincture  of  iodin  (1  to  2)  constitutes 
an  excellent  procedure  of  immediate  treatment;  if  necessary,  the 
clothing  must  first  be  cut  away. 

Among  the  countless  topical  applications  which  have  been 
recommended,  including  even  raw  scraped  potato  and  gooseberry 


452  ARTIFICIAL  DERMATITIDES 

jelly,  which  actually  relieves  the  pain,  the  preference  must  be 
accorded  to  oil-  and  lime-water  liniment,  vasolanolin,  naftalan,  or 
better  still,  to  the  special  oils  named  pyrolcol  and  phlyctol,  which 
are  highly  analgesic.  The  burn  is  covered  with  sterilized  com- 
presses soaked  in  one  of  these  products  and  with  a  thick  layer  of 
cotton.  The  dressings  should  be  changed  as  rarely  as  possible, 
except  in  case  of  suppuration.  Ichthyol,  glycerinated  thiol,  the 
salve  of  J.  Lucas-Championniere  and  the  product  named  ambrine, 
can  also  be  recommended.  Picric  acid  which  has  found  so  much 
favor,  should  be  rejected,  for  it  is  sometimes  dangerous. 

In  case  of  very  extensive  burns,  permanent  lukewarm  baths  give 
the  most  relief.  It  goes  without  saying  that  an  injection  of  mor- 
phin  should  not  be  refused  to  these  unfortunates  in  their  atrocious 
sufferings.  Camphorated  oil  and  adrenalin  by  subcutaneous  injec- 
tions and  enemas  with  physiological  salt  solution,  are  indicated  in 
grave  cases. 

Frost-bite. — Lesions  caused  by  freezing  differ  in  many  respects 
from  those  due  to  extreme  heat.  Cold  requires  a  longer  time  for 
its  action.  Immediate  pain  is  practically  absent  and  nothing  is  felt 
but  an  unpleasant  numbness;  pruritus  and  an  intolerable  burning 
sensation  being  delayed  until  the  reestablishment  of  the  circulation. 
It  is  almost  invariably  the  extremities  that  are  attacked  by  frost- 
bite; the  feet,  the  hands,  the  ears  and  the  nose.  In  the  first  degree 
the  region  is  of  a  cadaveric  pallor,  followed  by  intense  congestion. 
The  second  and  third  degree,  bleb-formation  and  sloughing,  usu- 
ally exist  together,  the  lesions  attaining  their  maximum  at  the 
periphery,  at  the  tips  of  the  toes,  the  fingers,  etc.  The  integument 
is  at  first  of  a  waxy  color,  the  region  is  anesthetic  and  lifeless.  It 
is  impossible  to  determine  to  what  depth  the  tissues  are  affected 
till  after  a  few  days. 

The  frozen  parts  must  be  very  cautiously  and  progressively 
warmed,  preferably  by  rubbing  them  with  snow;  they  may  be 
covered  only  very  gradually  and  the  surrounding  temperature 
raised  very  slowly.  The  subsequent  course  and  the  treatment  are 
the  same  as  in  gangrene  of  any  origin.  The  physician's  attitude 
should  be  as  conservative  as  possible  and  surgical  intervention  be 
restricted  to  the  removal  of  a  sequestrum.  Frost-bites  may  lead 
to  grave  mutilations. 

Chilblains  and  trench-foot  have  been  discussed  elsewhere  in  this 
book  (pp.  34,  35). 

Radiodermatitides. — The  .-c-jrays  as  well  as  radium,  mesothorium, 
etc.,  although  causing  no  sensation  whatever  at  the  moment  of 
application,  may  give  rise  to  a  series  of  cutaneous  manifestations, 
the  extreme  degrees  of  which  are  very  grave.  However,  as  there 
seems  to  be  no  individual  idiosyncrasy  toward  these  radiations, 


DERMATITIDES  DUE  TO  PHYSICAL  CAUSES  453 

these  disturbances  can  always  be  avoided.  They  depend  exclu- 
sively upon  the  dosage  and  quality  of  the  rays.  It  is  therefore  of 
the  utmost  importance  for  radiologists  to  employ  all  measuring 
instruments  belonging  to  an  outfit  of  this  kind,  to  be  entirely 
familiar  with  the  peculiarities  and  strength  of  their  apparatus,  to 
calculate  accurately  without  mistakes  the  distance  from  the  anti- 
cathode  to  the  skin  as  well  as  the  time  of  the  exposure. 

Unfavorable  sequelae  of  .r-ray  treatment  and  the  occupational 
radiodermatitides  of  radiologists  themselves  will  be  discussed 
separately  in  the  following. 

Therapeutic  Radiodermatitides. — The  cutaneous  reactions  due  to 
the  x-rays  do  not  appear  until  after  a  period  of  latency  or  incuba- 
tion, lasting  from  eight  to  twenty  days,  usually  from  fifteen  to 
seventeen  days.  The  slight  redness  which  may  supervene  on  the 
same  day  or  the  day  after  the  session  is  an  erythema  presumably 
due  to  the  light  rays  and  is  of  no  importance. 

Alopecia  of  the  scalp  regularly  appears  upon  a  dose  of  5  H,  so 
that  Sabouraud  was  enabled  to  formulate  the  radiotherapeutic 
treatment  of  the  tineas.  On  the  face  and  elsewhere,  alopecia  is 
not  a  constant  result  and  is  often  complicated  by  pigmentation  and 
cutaneous  atrophy. 

Beyond  a  dose  of  5  H  in  a  single  session,  or  if  exposures  of  the 
same  point  are  repeated  beyond  the  ratio  of  tolerance  as  established 
by  experience,  there  is  danger  of  a  series  of  manifestations,  to  be 
enumerated  in  the  following:  It  must  be  kept  in  mind  in  this  con- 
nection that  the  .T-rays  have  a  cumulative  effect;  that  nevertheless 
there  is  a  loss  with  time,  differently  estimated  by  authors,  but  which 
can  be  rated  at  1|  H  weekly;  finally,  that  certain  regions  are 
especially  susceptible,  notably  the  back  of  the  hands  and  feet,  the 
bridge  of  the  nose  and  the  forehead — perhaps  all  points  where 
the  integument  rests  upon  a  bony  surface. 

The  erythema,  the  first  degree  of  radiodermatitis,  punctiform  and 
pink  at  the  onset,  later  on  becomes  a  uniform  dusky  or  purplish 
red;  it  gives  rise  to  severe  itching,  then  to  desquamation,  lasting  for 
a  few  days  to  a  week,  rarely  longer. 

The  erythema  is  usually  followed  by  pigmentation  which  may  last 
for  months,  varying  greatly  in  different  individuals. 

Blebs,  scattered,  grouped,  or  confluent  upon  an  erythematous 
base,  may  develop  after  a  more  energetic  exposure  and  are  often  the 
forerunners  of  ulcers  or  sloughs. 

Ulceration  usually  burrows  on  the  floor  of  a  bleb  which  has 
suppurated.  It  is  dusky  red,  smooth  or  slightly  granular,  with 
gently  sloping  borders,  of  extremely  variable  shape  and  extent,  with 
scanty  serous  oozing.  It  is  accompanied  by  burning,  tearing, 
lancinating  pains,  often  of  extreme  severity,  preventing  sleep  and 


454  ARTIFICIAL  DERMATITISES 

constituting  a  serious  torment.  Radiodermatitic  ulcers  take  a 
sluggish  course,  first  progressive,  then  slowly  retrogressive;  they 
often  last  several  months  or  even  years.  I  have  pointed  out  that 
sometimes  they  may  simulate  superficial  epitheliomas,  biopsy  being 
necessary  for  a  diagnosis. 

Sloughing  develops  primarily,  or  under  a  blister,  or  around  an 
ulceration.  The  slough  is  white,  then  brown  or  black,  hardly 
encroaching  upon  the  cutis  or  on  the  contrary  also  involving  the 
cellular  tissue,  the  tendons,  the  aponeuroses,  etc-.,  briefly,  all  the 
subjacent  parts.  It  causes  frightful  pains,  radiating  to  a  distance, 
of  a  neuritic  character.  The  course  is  very  slow;  demarcation  and 
elimination  are  long  delayed.  Relapses,  with  reproduction  of 
sloughs  at  the  periphery  or  below  are  not  uncommon.  A  cure 
requires  months  and  may  be  followed  by  recurrences  in  situ.  A 
very  instructive  case  of  ulcerative  radiodermatitis  came  under  my 
personal  observation  and  was  published  in  the  Annates  de  Derma- 
tologie,  October,  1913.  An  ulcer  on  the  breast  of  a  young  woman, 
occurring  six  months  after  a  final  .r-ray  session,  healed  in  five  months; 
it  reappeared  spontaneously,  without  a  new  radiation,  over  eleven 
years  afterward  and  at  this  time  still  presented  the  histological 
structure  of  a  recent  radiodermatitis.  It  must  be  concluded  that 
the  pathological  process  persists  practically  indefinitely. 

The  patches  of  sclerous  radiodermatitis  which  follow  upon  an  ulcer, 
but  may  also  develop  as  the  sequel  of  a  simple  erythema  or  bleb, 
have  a  pathognomonic  appearance.  There  is  an  indistinctly  out- 
lined spot  of  white,  tense  and  indurated  sclerosis,  smooth  and 
interspersed  with  serpentine  or  arboreal  telangiectases;  or  there 
may  be  an  undulating,  scaly,  lardaceom  surface,  mottled  with  pig- 
mentary spots  and  purplish  macules,  adherent  and  not  readily 
folded;  finally,  a  thickened  and  deformed  genuine  cicatrix  may  be 
present.  These  three  degrees  of  lesions  may  coexist  in  concentric 
zones. 

Observers  have  been  impressed  with  the  analogy  between  the 
patches  of  white  or  lardaceous  sclerosis  in  radiodermatitides  and 
scleroderma  in  patches,  which,  however,  is  more  sharply  outlined; 
and  also  with  xeroderma  pigmentosum  and  senile  degeneration,  but 
the  last-named  affections  are  diffuse  and  regional  (Chapter  XVII). 

Complications  due  to  overexposure  to  the  .r-rays  should  no  longer 
occur  at  the  present  day.  Before  any  new  application,  it  must  be 
kept  in  mind  that  the  patient  may  forget  to  mention,  or  try  to 
conceal  a  recent  .r-ray  treatment.  Careful  inquiries  must  therefore 
be  made. 

Occupational  Radiodermatitides. — Radiologists,  unless  carefully 
observant  of  the  most  scrupulous  precautions,  are  exposed  to  a 
diffuse,  insidious,  chronic  and  progressive  radiodermatitis,  which  is 


DERMATITIDES  DUE  TO   PHYSICAL  CAUSES  455 

always  grave  and  may  become  fatal.  The  hands,  sometimes  the 
face,  are  the  parts  naturally  most  affected.  The  fingers  at  first 
become  cyanotic;  the  epidermis  becomes  dry  and  peels  off,  the 
skin  becomes  swollen  and  cracked,  retracting  especially  around  the 
nails  which  likewise  become  furrowed,  split,  break  and  exfoliate. 
The  patient  has  a  constant  feeling  of  constriction. 

The  appearance,  which  is  at  first  suggestive  of  frostbite  or  of 
dysidrosis,  later  on  approximates  that  of  the  eczematized  prurigos; 
but  the  mixture  of  atrophy,  telangiectasis,  verrucosities,  etc.,  on 
the  other  hand,  lends  the  clinical  picture  an  analogy  with  xeroderma 
pigmentosum  and  with  arsenical  keratosis. 

The  occurrence  of  epithelioma  of  the  papillary,  later  the  lobu- 
lated  type,  is  not  very  rare  in  these  chronic  radiodermatitides. 
It  cannot  be  stated  outright  that  x-rays  give  rise  to  cancer,  but  it 
must  be  admitted  that  their  cumulative  effect  leads  to  a  cutaneous 
dystrophy  on  which  epithelioma  more  easily  develops  in  the  same 
sense  as  on  the  senile,  arsenical,  xerodermic  dystrophies,  or  on 
cicatrices  in  general.  The  pioneer  radiologists  who  worked  at  a 
time  when  the  remote  dangers  of  the  x-rays  were  still  unknown, 
have  nearly  all  expiated  their  unwitting  lack  of  caution  with  severe 
mutilations  and  in  some  instances  with  their  lives. 

Treatment. — This  must  be  primarily  prophylactic.  The  applica- 
tion of  x-rays  and  radium  requires  scrupulous  attention  and  con- 
siderable experience  and  caution.  It  must  moreover  be  kept  in  mind 
that  those  cutaneous  regions  which  have  once  been  overexposed 
retain  indefinitely  a  remarkable  vulnerability  toward  mechanical, 
physical,  chemical  and  medicinal  noxious  agents  and  especially  a 
susceptibility  to  x-rays;  they  suggest  fire  smouldering  under  the 
ashes. 

Erythema  or  blebs  are  treated  like  burns.  Against  the  pigmen- 
tations, hydrogen  peroxide  or  naphthol  creams  may  be  employed. 
Occupational  radiodermatitides,  sclerotic  radiodermatitides  and 
ulcers  do  well  under  repeated  baths  and  moist  occlusive  dressings, 
notably  a  chamomile  infusion  mixed  with  potash,  1  per  10,000; 
inunctions  with  vaselin-lanolin  cream  and  lead-water,  or  with 
glycerol  of  starch.  Stimulating,  antiseptic,  analgesic  topical  appli- 
cations and  reducing  agents  in  general  should  be  avoided.  Oily 
dressings  are  often  readily  tolerated. 

Static  baths,  high-frequency  currents  and  even  heliotherapy 
have  been  recommended,  but  cannot  be  unconditionally  endorsed. 
In  certain  cases,  the  excision  of  an  ulcer  may  be  indicated  when 
this  is  feasible,  or  the  destruction  through  superheated  air.  [Radi- 
cal surgical  excisions  of  deep  x-ray  ulcers  followed  by  grafting  not 
only  gives  prompt  relief  to  the  intolerable  pains  but  is  the  best 
insurance  against  the  subsequent  development  of  epithelioma.] 


456  ARTIFICIAL  DERMATITIDES 

Of  recent  years,  especially  in  America,  attempts  have  been  made 
to  treat  the  spots  of  keratosis  and  the  incipient  epitheliomas  of 
radiologists,  through  applications  of  radium.  This  paradoxical 
therapy,  which  has  the  advantage  of  being  painless,  seems  to  have 
yielded  really  successful  results. 

TOXIDERMAS. 

The  number  of  substances  of  all  kinds  which  may  damage  the 
skin  is  so  great,  their  effects  are  so  multiple  and  variegated  that 
an  entire  volume  might  be  devoted  to  this  subject  without  exhaust- 
ing it.  I  shall  limit  myself  to  a  consideration  of  those  features 
which  have  the  most  important  practical  bearing. 

Etiology. — In  the  etiology  of  the  toxidermas  we  have  to  deal 
not  only  with  poisons,  a  group  of  substances  actually  incapable  of 
definition,  but  also  with  countless  medicinal  agents,  the  list  of 
which  is  extended  every  day  through  the  achievements  of  chemistry, 
as  well  as  many  products  employed  in  the  industries,  in  the  house- 
hold, for  the  care  of  the  person,  etc.,  and  finally  a  certain  number  of 
foods  and  drinks. 

According  as  the  injurious  substance  has  acted  through  appli- 
cation or  friction  on  the  skin,  or  by  its  having  been  ingested  and 
absorbed,  a  distinction  is  made  between:  External  toxidermas,  or 
the  direct  artificial  eruptions  of  Bazin,  on  the  one  hand;  and  the 
internal  toxidermas,  or  indirect  artificial  or  pathogenetic  eruptions 
of  Bazin  on  the  other. 

In  the  latter  case,  the  digestive  mucosa  most  frequently  serves 
as  the  avenue  of  entrance;  exceptionally,  the  urogenital,  respiratory, 
or  even  the  conjunctival  mucosa  may  be  responsible;  finally,  the 
injurious  substance  may  have  been  introduced  by  the  hypodermic 
route,  which  is  becoming  more  and  more  used  for  therapeutic 
purposes;  eruptions  due  to  sera  form  an  interesting  group  of  this  class. 

Symptoms  and  Diagnosis. — A  few  general  remarks  will  suffice  in 
this  connection. 

Three  points  have  to  be  settled:  (1)  The  presence  of  a  toxi- 
derma;  (2)  its  external  or  internal  origin;  (3)  the  discovery  of  the 
injurious  substances. 

1.  As  there  exists  no  characteristic  sign  of  toxidenna  in  general, 
the  prudent  physician  will  make  it  his  rule,  when  dealing  with  any 
dermatoses  the  diagnosis  of  which  is  not  at  once  evident,  to  think 
of  the  possibility  of  an  artificial  eruption  and  to  pursue  his  inquiry 
in  this  direction. 

It  would  be  a  mistake  to  assume  that  the  eruption  is  the 
entire  disease  in  the  toxidermas.  Accessory  pathological  phenomena 
are  frequent.     Aside  from  the  painful,  burning,  tense  and  espe- 


TOXIDERMAS  457 

cially  itching  sensations  which  usually  accompany  the  eruptions, 
general  disturbances  may  also  be  observed,  such  as  malaise,  excite- 
ment, headache,  insomnia,  various  digestive  disturbances,  a  pale 
or  yellowish  complexion,  etc.  Fever  may  be  associated  with  these 
symptoms;  it  is  usually  moderate  and  ephemeral;  exceptionally  it 
may  be  very  high. 

The  internal  toxidermas  are  accompanied  in  certain  cases  by 
enanthema  of  the  buccal,  pharyngeal,  nasal,  conjunctival,  genital 
mucosae,  sometimes  even  by  edema  of  the  larynx;  this  may  be  not- 
ably the  case  in  iodism,  hydrargyria,  etc.  It  follows  from  this 
fact  that  the  differential  diagnosis  of  certain  toxidermas  from  the 
eruptive  fevers  or  from  various  infections  derived  from  a  mucous 
membrane,  may  present  very  serious  difficulties. 

2.  The  external  or  internal  origin  of  a  toxiderma  is  sometimes 
evident  at  the  first  glance ;  the  type  of  the  eruption,  its  topographical 
distribution,  its  localization  or  generalization  may  furnish  valuable 
indications  in  this  respect.  In  other  cases,  however,  this  question 
cannot  be  settled  off  hand.  It  may  happen  that  a  substance  applied 
to  the  skin  acts  both  locally  and  by  absorption.  Hence  the  boun- 
dary between  the  external  and  internal  toxidermas  is  not  absolute. 

3.  In  the  determination  of  the  injurious  agent,  it  is  essential  not 
to  overlook  the  following  considerations:  Among  the  various 
eruptions  which  may  be  caused  by  the  same  substances  some  are 
specific,  plainly  characteristic  of  the  cause  which  has  produced 
them  (example:  some  bromide  eruptions,  some  antipyrinides  and 
arsenical  keratosis);  others  are  less  characteristic  and  justify  only 
a  presumptive  diagnosis  (example:  iodide  acne,  bromide  acne); 
still  others  are  commonplace,  resulting  from  the  action  of  many 
different  kinds  of  substances  (example :   urticaria) . 

It  is  a  matter  of  common  observation  that  a  given  individual 
reacts  to  the  same  substance  by  an  always  identical  eruption, 
without  a  proportion  necessarily  existing  between  the  dose  and 
the  degree  of  the  reaction.  Frequently  also  the  same  individual 
reacts  by  the  same  eruption  toward  several  different  substances. 
It  seems  in  such  cases  that  the  patient  makes  the  eruption,  the 
injurious  substance  merely  playing  an  accidental  determining  part 
which  elucidates  and  reveals,  as  it  were,  an  existing  pathological 
tendency.  Its  action  has  been  likened  to  that  of  the  fingers  on  the 
trigger  of  a  loaded  gun.  It  goes  without  saying  that  the  artificial 
eruptions  which  appear  under  the  influence  of  a  variety  of  causes, 
are  necessarily  of  an  ordinary  form. 

Pathogenesis.  —  The  pathogenesis  of  the  toxidermas  must  be 
studied  from  the  standpoint  of:  (1)  The  conditions  under  which 
the  injurious  action  of  certain  substances  is  developed;  (2)  the 
mechanism  of  their  action. 


158  ARTIFICIAL  DERMATITIDES 

1.  CONDITIONS  OF  INJURY— The  nature-of  a  substance— its 
chemical  properties — sometimes  account  for  the  action  which  it 
exerts  upon  the  skin;  this  is  true  for  the  caustic  agents,  for  sub- 
stances having  a  strong  reducing  or  oxidizing  action,  etc. 

In  other  eases,  substances  arc  concerned  which  possess  special 
biological  properties  and  under  these  conditions  one  must  essen- 
tially remain  satisfied  with  the  phrase:  Quia  est  in  eis  qucedam 
virtus.     .     .     .     The  vesicants  or  rubefacients  belong  to  this  group. 

Provided  that  the  conditions  of  dosage,  concentration  and  dura- 
tion of  action  are  present,  the  substances  in  this  first  class  are 
sure  to  affect  any  human  skin,  without  a  predisposition  of  any 
kind  being  required.  The  resulting  dermatitides  are  external  toxi- 
dermas  through  direct  contact  and  may  be  designated  as  traumatic 
toxidermas  or  chemical  dermatitides  (example:  sulphuric  acid,  croton 
oil,  etc.). 

Other  external  or  internal  toxidermas  are  due  to  bodies  whose 
chemical  character  and  general  biological  properties  do  not  explain 
this  influence,  which  moreover  is  exerted  only  in  an  inconstant, 
accidental,  even  exceptional  manner,  so  that  one  is  compelled  to 
attribute  the  abnormal  reaction  to  conditions  of  territory,  intoler- 
ance, or  individual  susceptibility. 

As  a  matter  of  fact,  there  exists  no  sharp  boundary  line  between 
the  groups  of  substances  acting  on  all  persons  alike  (example: 
caustic  potash),  those  acting  on  many  persons  (example:  carbolic 
acid),  or  those  acting  only  exceptionally  (example:  iodoform). 
However,  in  the  presence  of  an  inconstant  effect,  not  explained  by 
the  conditions  of  quality,  quantity  and  duration  of  action,  one 
must  necessarily  suspect  the  intervention  of  a  personal  factor,  a 
special  susceptibility,  or  a  peculiar  capacity  of  reaction.  This  is 
what  is  meant  by  predisposition. 

Predisposition  and  Idiosyncrasy. — The  question  of  predisposition 
to  disease,  which  is  connected  with  that  of  immunity,  has  a  scope 
far  exceeding  the  limits  of  a  book  of  this  kind.  The  problem  may 
be  studied  from  a  general  point  of  view  in  connection  with  infec- 
tions, intoxications,  nutritional  diseases,  etc.  I  have  frequently 
had  occasion  to  allude  to  predisposition  in  other  chapters,  but  as 
it  plays  the  most  evident  part  in  the  toxidermas,  a  few  lines  will 
here  be  devoted  to  its  discussion. 

In  the  first  place,  it  must  be  emphasized,  with  Jadassohn,  that 
the  term  predisposition  is  applied  to  two  phenomena  which  up  to 
a  certain  point  are  distinct: 

1.  Increased  sensibility,  or  hyyersensibility,  causing  a  given  indi- 
vidual to  react  to  a  minimum  dose,  greatly  below  that  which  is 
generally  injurious,  but  the  form  of  the  reaction  is  not  unusual.  It 
has  been  stated  that  in  case  of  hypersensibility,  the  question  of 


TOXIDERMAS  459 

dosage   of  the  injurious  agent  is  of  no  importance,   but  this   is 
obviously  an  exaggeration. 

2.  Idiosyncratic  intolerance,  in  which  an  individual  experiences 
injurious  effects  from  a  given  substance  which  it  would  not  produce 
in  any  dose  on  a  normal  individual. 

It  is  not  always  possible  to  decide  which  of  these  phenomena  is 
concerned  in  a  special  case;  moreover,  there  exist  varieties  inter- 
mediate between  these  two  forms  of  predisposition. 

In  current  usage,  the  word  predisposition  is  employed  rather  for 
a  sensibility  the  reasons  of  which  are  suggested  by  a  disturbance  of 
the  general  health ;  when  the  cause  of  the  intolerance  is  absolutely 
mysterious,  one  resorts  to  Greek  and  speaks  of  idiosyncrasy. 

The  real  nature  of  so-called  predisposition  is  unknown.  Clinical 
experience  teaches  that  it  may  be:  general,  the  skin  proving  sus- 
ceptible to  all  irritants;  or  special,  intolerance  existing  only  toward 
a  single  substance  or  group  of  substances;  absolute  or  relative, 
namely  more  or  less  independent  of  the  dose  and  the  mode  of 
introduction.  A  medicinal  agent  is  sometimes  tolerated  when  it  is 
ingested  or  injected,  but  proves  injurious  on  external  application; 
this  is  common  with  mercury  and  the  rule  with  iodoform,  for 
instance.  It  is  noteworthy  that  poisons  when  ingested  reach  the 
skin  in  a  lower  concentration,  especially  as  the  liver  retains  a 
considerable  share. 

Predisposition  is  congenital  and  sometimes  even  familial,  or 
acquired.  It  is  finally  either  permanent  or  temporary  and  may 
recur  a  number  of  times. 

The  causes  of  the  intolerance  are  generally  obscure,  frequently 
multiple  and  inextricable. 

Often  a  general  disturbance  must  be  held  responsible,  due  to  an 
infectious  disease,  physical  or  mental  overstrain,  a  physiological 
phenomenon  such  as  menstruation,  pregnancy,  the  menopause,  etc. 
A  local  irritation  or  infection  may  invite  a  toxiderma;  seborrhea 
and  acne  vulgaris  are  known  to  predispose  to  iodide,  bromide  and 
tar  acne,  just  as  dental  caries  and  gingivitis  provoke  mercurial 
stomatitis. 

Digestive  disturbances,  preexisting  or  caused  by  the  toxic  agent 
itself,  favor  the  development  of  toxidermas;  changes  in  the  gastro- 
intestinal motility,  secretions,  fermentations,  etc.,  may  lead  to 
absorption  of  abnormal  products  or  to  a  reaction  of  these  products 
on  the  medicinal  substance.  In  the  bromide  and  iodide  eruptions, 
for  instance,  the  role  of  digestive  disturbances  seems  probable. 

In  other  cases,  hepatic  inefficiency  or  renal  insufficiency  are  held 
responsible,  meaning  a  diminution  in  the  antitoxic  function  of  the 
liver  or  the  excretory  action  of  the  kidneys;  or  functional  disturb- 
ances of  the  cardiovascular  apparatus,  the  nervous  system,  or  the 


460  ARTIFICIAL  DERMATITIDES 

glands  of  internal  secretion  may  sensitize  the  skin  or  bring  about 
one  or  another  eruptive  form  and  localization. 

Idiosyncratic  intolerance  may  subside  in  some  cases  under  a 
gradual  and  continuous  administration,  with  establishment  of 
habituation  or  nrithridatization.  One  may  assume  that  the  skin 
has  acquired  a  greater  resistance,  or  that  elimination  through  the 
emunctories  has  improved,  or  that  an  immunization  has  occurred, 
of  which  the  phenomenon  of  so-called  anti-anaphylaxis  is  undoubt- 
edly an  example. 

The  opposite  is  noted  in  respect  to  certain  bodies  which  are  cap- 
able of  accumulation  in  the  organism.  Digitalis,  bromin,  arsenic, 
chloral  and  even  iodin,  etc.,  are  known  to  belong  to  this  group. 
However,  accumulation  accounts  only  to  a  very  limited  degree  for 
idiosyncrasy. 

The  usual  course  of  events  is  as  follows:  An  individual,  appar- 
ently free  from  anomalies,  is  attacked,  in  consequence  of  the  appli- 
cation or  ingestion  of  some  alimentary  or  medicinal  substance,  by 
an  eruption  of  an  erythematous,  urticarial,  eczematous  or  other 
type. 

If  he  has  never  before  absorbed  this  substance  or  come  in  con- 
tact with  it,  the  case  belongs  simply  to  the  class  of  idiosyncratic 
intolerance.  Sometimes,  however,  he  has  previously  tolerated  it 
without  disturbance.  In  the  latter  case,  whether  the  toxidermic 
attack  has  occurred  at  the  time  of  one  of  the  disturbances  mentioned 
above  or  in  the  absence  of  a  demonstrable  adjuvant  factor  it  is 
almost  the  rule  for  this  individual  to  be  thereafter,  for  a  fairly  long 
or  even  indefinite  period,  hypersensitized  to  such  a  degree  that  the 
most  minute  dose  of  the  injurious  body,  or  perhaps  of  several  others, 
will  give  rise  to  a  fresh  eruptive  attack. 

This  acquired  sensibility  has  very  naturally  been  interpreted  by 
some  as  a  peculiar  instance  of  anaphylaxis,  to  which  we  must  devote 
a  few  words. 

Anaphylaxis. — Ch.  Richet  discovered  (in  1902)  and  gave  this  name 
to  the  special  sensibility  produced  by  the  preliminary  injection  of 
certain  toxalbumins;  it  differs  from  the  accumulation  of  toxic  agents 
in  not  manifesting  itself  immediately  but  only  after  a  certain 
period  of  incubation.  The  conditions  under  which  he  observed  this 
phenomenon  and  the  principal  facts  concerning  it  are  as  follows: 

Experimenting  on  dogs  with  the  poison  of  actinia  [sea-anenomes], 
Richet  demonstrated  that  an  animal  injected  with  a  sublethal  dose 
will  recover;  a  new  similar  dose  injected  a  few  days  later  remains 
without  effect;  but  if  at  the  end  of  two  to  three  weeks  the  same  dog 
is  injected  with  an  even  ten  or  twenty  times  smaller  dose,  he  will 
suddenly  develop  very  serious  or  even  fatal  symptoms.  These 
symptoms,  the  essential  phenomenon  of  which  is  a  sideration  of 


TOXIDERMAS  461 

the  nervous  system  with  lowering  of  the  arterial  pressure,  constitute 
the  "anaphylactic  shock."  Richet  assumes  that  the  first  injection 
has  stimulated  in  the  blood  the  formation  of  a  toxogenin,  which  on 
contact  with  a  new  dose  of  its  antigen  combines  with  it  to  form  a 
powerful  poison,  the  apotoxin. 

The  experiments  of  Arthus,  Theobald  Smith  and  others  have 
shown  that  this  anaphylactogenetic  power  belongs  not  only  to 
toxic  agents,  but  that  the  injection  of  the  blood-serum  of  an  animal 
into  an  animal  of  another  species  will  similarly  sensitize  it  toward 
this  serum.  It  is  now  known  that  in  a  general  way  all  albuminoid 
substances  will  produce  anaphylaxis. 

In  addition  to  this  direct  and  "active"  anaphylaxis,  Richet  dis- 
covered that  there  exists  a  "passive"  anaphylaxis,  in  so  far  as  an 
animal  may  be  sensitized  by  injecting  into  it  the  serum  of  a  sensi- 
tized animal.  I  have  previously  mentioned  that  the  discovery  of 
passive  anaphylaxis  has  been  utilized  in  proving  the  origin  of  certain 
urticarial  eruptions,  those  due  for  instance  to  pork  or  mussels. 

The  term  anti-anaphylaxis  denotes  the  process  by  which  the 
outbreak  of  an  anaphylactic  shock  or  crisis  is  prevented.  Credit 
is  due  to  Besredka  for  having  shown  that  the  preliminary  injection 
of  small  doses  of  the  determining  serum  permits  the  injection  of 
the  total  dose  one  hour  later  without  disturbance.  A  very  slowly 
administered  injection  is  in  itself  anaphylactic  to  a  certain  degree. 
I  have  pointed  out  that  a  rational  attempt  has  been  made  to  treat 
urticaria  by  anti-anaphylaxis.  This  therapeutic  method  will  per- 
haps find  numerous  and  important  applications  in  the  future. 

That  medicinal  intolerance  and  anaphylaxis  are  not  identical  is 
apparent  on  the  following  grounds:  In  the  first  place,  in  spite  of 
some  contradictory  experiments,  it  has  not  been  established  that 
non-colloid  substances  may  produce  an  anaphylactic  state. 
Furthermore,  it  is  not  uncommon  for  a  toxiderma  to  manifest 
itself  at  the  first  use  of  a  drug;  in  these  cases,  at  any  rate,  there  is 
nothing  like  the  period  of  incubation  which  is  required  for  the  devel- 
opment of  genuine  anaphylaxis.  Achard  and  Flandin  were  unable 
to  produce  in  guinea-pigs  either  an  active  anaphylaxis  with  medic- 
inal agents  or  a  passive  anaphylaxis  by  injecting  them  with  the 
serum  of  patients  suffering  from  eruptions  due  to  antipyrin,  iodo- 
form, or  quinine.  Pending  further  research,  medicinal  intolerance 
must  therefore  be  interpreted  as  a  simple  hypersensibility,  not 
partaking  of  an  anaphylactic  character. 

It  is  necessary  to  point  out,  however,  that  Ch.  Richet  showed  in 
1910  that  animals  which  have  been  sensitized  by  an  anaphylacto- 
genetic substance  are  to  a  certain  degree  sensitized  at  the  same  time 
toward  all  poisons  even  crystalloids. 

Looking  at  the  question  of  idiosyncrasy  from  a  wider  perspec- 


462  ARTIFICIAL  DERM  AT  in  DBS 

tive,  one  may  well  ask  with  him  if,  just  as  human  beings  differ  in 
their  psychic  personality,  they  are  not  each  endowed  with  a  humoral 
personality  peculiar  to  the  individual;  the  personal  differences  in 
the  Immoral  make-up,  being  due  to  heredity,  ingesta,  as  well  as  the 
multiple  intoxications  and  infections  which  they  have  experienced 
in  the  course  of  existence,  accounting  for  the  differences  in  the 
reactions  toward  injurious  factors. 

2.  PATHOGENIC  MECHANISM— -It  is  not  necessary  for  the 
pathogenic  mechanism  of  the  toxidermas  to  be  uniform  and  always 
identical;  it  is  not  even  probable  that  this  is  the  case. 

The  interpretation  of  external  toxiderma  is  not  difficult,  the 
condition  represents  a  sort  of  local  chemical  traumatism.  It  must 
be  kept  in  mind,  however,  that  in  order  to  cause  a  reaction,  the 
injurious  substance  must  pass  through  the  inert  horny  layer.  The 
absorption  of  the  normal  skin  is  demonstrable  only  for  volatile 
substances  (ethereal  oils,  iodin,  mercury,  etc.),  certain  fatty  sub- 
stances and  the  keratolytic  substances  (salicylic  acid).  It  has 
been  shown,  however,  that  potassium  iodide,  antipyrin  and  some 
alkaloids  may  penetrate  the  skin  under  certain  conditions.  More- 
over, the  slightest  fissure  of  the  horny  layer  constitutes  a  portal  of 
entrance. 

Many  substances  give  rise  to  eruptions  when  absorbed  by  the 
external  as  well  as  by  the  internal  route;  one  is  led  to  assume  that 
the  injurious  action  is  exerted  as  an  idiosyncrasy  on  the  constit- 
uents of  the  skin  itself.  It  is  certainly  amazing  to  see  to  what 
degree  the  cutaneous  sensibility  must  be  augmented  for  a  reaction 
to  occur  with  the  infinitesimal  quantity  of  substance  carried  by  the 
blood  stream  to  a  given  square  centimeter  of  skin;  but  one  is  pre- 
pared to  admit  this  hypersensibility  in  view  of  what  has  been 
established  in  the  external  toxidermas. 

It  is  very  remarkable  that  this  predisposition  is  often  strictly 
localized  and  limited  to  a  given  territory  which  nothing  seems  to 
predetermine  for  this  selection;  the  typical  example  of  the  anti- 
pyrinides,  however,  compels  the  recognition  of  this  fact. 

It  has  been  supposed  that  the  vasomotor  or  trophic  (?)  nervous 
system,  damaged  by  the  circulating  poison,  might  intervene  in  the 
localization  of  the  internal  toxidermas,  a  metameric  distribution 
of  which  has  sometimes  been  reported.  But  the  inflammatory 
character  of  the  great  majority  of  toxidermic  lesions  renders  the 
idea  of  a  purely  nervous  pathogenic  influence  rather  improbable. 

The  role  of  the  blood  is  indispensable  in  all  not  strictly  local 
toxidermas;  the  injurious  agent  must  be  transported  either  to  the 
nervous  elements  or  to  the  skin.  In  a  few  exceptional  cases,  the 
blood  medium  is  even  morphologically  altered;  E.  Hoffmann  and 


TOXIDERMAS  FROM  EXTERNAL  CAUSES  463 

others  have  noted  eosinophilia  in  hydrargyria  and  Leredde  has 
demonstrated  it  in  iodism. 

The  toxidermas  were  formerly  very  simply  referred  to  elimina- 
tion, or  to  an  attempted  elimination  of  the  toxic  agent  by  the  cuta- 
neous tissues.  The  purifying  function  thus  attributed  to  the  skin 
is  now  known  to  be  in  reality  very  limited,  if  not  absent.  It  has 
not  been  demonstrated  that  in  eruptions  due  to  iodides  or  bromides, 
for  instance,  the  altered  skin  contains  a  larger  quantity  of  the 
metalloid  than  the  neighboring  skin.  The  positive  findings  of 
Adamkiewicz  for  iodin  and  of  Gutman  for  bromin  are  offset  by  a 
mass  of  negative  results;  Pasini  believes  that  in  bromide  eruptions 
the  bromin  exists  in  an  organic  combination  not  easily  demonstrable. 
As  to  arsenic,  it  is  known — and  the  fact  has  been  confirmed  by  the 
careful  analyses  of  Arm.  Gautier — that  the  epidermis  and  its  adnexa, 
hairs  and  nails,  contain  a  proportion  of  the  toxic  agent  relatively 
so  high  that  the  epidermic  tissues  must  really  be  considered  as 
normal  routes  of  elimination  of  arsenic;  but  the  condition  exists 
both  in  the  presence  and  absence  of  cutaneous  lesions. 

In  certain  toxidermas,  the  part  played  by  microbic  infections, 
especially  through  pyococci,  is  very  evident.  Thus  the  iodide, 
bromide  and  tar  acnes,  the  eruption  due  to  thapsia,  the  miliaria  alba 
following  mercury  and  the  application  of  plasters,  contain  staphylo- 
cocci with  such  regularity  and  abundance  that  the  germs  may  be 
regarded  as  practically  obligatory  collaborators  of  the  toxic  agent. 

The  eczematous  and  bullous  toxidermas  likewise  open  the  door 
to  the  same  agents  which  may  lead  to  generalization  and  per- 
sistence of  an  originally  toxic  eruption,  the  transportation  being 
facilitated  by  scratching. 

TOXIDERMAS   FROM   EXTERNAL   CAUSES. 

This  section  comprises  different  groups  of  cases,  according  as  the 
eruption  results  from:  (A)  Badly  tolerated  medicinal  applications, 
external  medicinal  eruptions.  (B)  Application  of  counter-irritants 
or  caustics,  induced  dermatitides.  (C)  Substances  used  by  the 
patient  in  his  work,  occupational  dermatitides.  (D)  Vegetable  or 
animal  poisons,  dermatitides  venenatce.  (E)  Applications  made  for 
the  purpose  of  malingering,  simulated  dermatitides. 

The  morphological  appearances  assumed  by  these  various  toxi- 
dermas have  been  sufficiently  described  in  the  first  portion  of 
this  book.  They  belong  especially  to  the  following  groups :  eryth- 
emas, urticaria,  eczema,  pustules,  bullae,  ulcerations,  gangrenes, 
dyschromias  and  folliculoses. 

A.  External  Medicinal  Eruptions. — The  therapeutic  substances 
which  are  capable  of  producing  lesions  or  reactions  that  the  physi- 
cian had  not  expected,  are  innumerable. 


464  ARTIFICIAL  DERM  AT  IT  IDES 

W'nivr,  either  pure  or  containing  anodyne  products,  employed  in 
prolonged  baths,  in  moist  dressings,  etc.,  macerates  the  epidermis, 
thereby  predisposing  to  pyococcal  infections.  The  phenomenon 
of  the  "crop"  (poussee),  so  common  in  the  majority  of  watering 
places,  is  to  a  large  extent  referable  to  the  water.  Poultices  act  in 
the  same  way,  particularly  when  the  linseed  has  become  rancid 
and  therefore  irritating.  Excessive  washing  with  soap  and  alkaline 
or  sulphur  baths  may  cause  dryness  of  the  skin,  redness,  desquama- 
tion and  the  formation  of  vesicles. 

The  majority  of  fatty  or  resinous  substances  which  enter  into  the 
composition  of  plasters  are  capable,  as  a  result  of  maceration,  of 
irritating  the  epidermis  and  exciting  eruptions  accompanied  by  an 
abundant  growth  of  pyococci. 

,  I  ntiseptics,  even  the  weakest,  such  as  boric  acid,  sodium  biborate, 
etc.,  may  prove  irritative  to  the  skin.  Some  remedies  of  this  group 
are  entitled  to  special  mention. 

Pure  carbolic  acid  is  a  caustic  producing  a  white  slough,  almost 
without  inflammatory  reaction;  strong  or  even  weak  improperly 
prepared  solutions  often  give  rise  to  carbolic  acid  erythema,  some- 
times to  vesicle  formation  with  edema,  carbolic  acid  eczema,  and 
even  to  gangrene  when  employed  in  dressings,  a  fact  which  must 
not  be  overlooked  (Chapter  XV). 

Tincture  of  arnica,  much  liked  by  the  laity  for  the  dressing  of 
contusions,  has  often  a  pronounced  eczematizing  action. 

Formol  hardens  the  epidermis,  which  cracks  and  peels  off,  under 
simultaneous  production  of  a  dermatitis  which  may  be  necrotic. 

Salol,  a  compound  of  carbolic  and  salicylic  acids,  is  like  its  com- 
ponents frequently  the  origin  of  persistent  and  progressive  erythe- 
mato-vesicular  dermatitis.  As  an  admixture  in  tooth-washes  or 
"catarrh  powders,"  it  gives  rise  to  orbicular  eczemas  of  the  lips  or 
nostrils  which  persist  indefinitely  when  not  traced  to  their  real 
cause. 

Iodoform  is  especially  to  be  dreaded  in  cases  of  idiosyncrasy. 
Following  its  application  in  even  trifling  amounts,  the  neighboring 
skin  becomes  deeply  reddened  and  covered  with  small  confluent 
vesicles.  This  dermatitis  is  accompanied  by  an  erysipeloid  or 
psendo-phlegmonous  edema,  especially  on  the  face  or  on  the  geni- 
tals; it  may  even  become  generalized.  The  eruption  terminates 
by  desiccation  or  by  suppuration;  recovery  takes  place  only  after 
two  or  three  weeks.  It  is  certain  that  iodoform  dermatitis 
results  rather  from  the  contact  of  the  iodoform  with  the  epidermis 
than  with  the  cavity  of  an  ulcer  or  a  wound,  or  even  with  the 
surface  of  a  mucous  membrane. 

General  symptoms,  delirium  and  even  death,  have  also  been 
observed  and  are  referable  to  the  absorption  of  this  remedy. 


TOXIDERMAS  FROM  EXTERNAL  CAUSES 


465 


The  substitutes  for  iodoform,  iodol,  aristol,  europhen,  airol,  etc., 
are  less  frequently  injurious.  Orthoform  may  excite  an  erysipeloid 
and  gangrenous  dermatitis. 

Mercury  and  its  salts,  in  external  applications  more  often  than 
after  ingestion  or  injection,  give  rise  in  predisposed  persons  to 
eruptions  known  as  cutaneous  hydrargyria.  It  is  true  that  the 
mechanical  factor  and  the  nature  of  the  vehicle  also  play  a  role  in 
mercurial  inunctions;  but  the  eruption  frequently  follows  upon  a 
simple  application  of  blue  ointment  (Fig.  1T>)  or  dressings  with 
sublimate,  biniodide,  cyanide,  mercurial  plaster  and  even  applica- 
tions of  calomel. 


Fig.   143. — Cutaneous  hydrargyria  of  eight  days'  standing,  occurring  a  few  hours 
after  inunction  of  the  groins  and  the  axillse  with  blue  ointment  for  phthiriasis. 


The  symptoms  consist,  in  the  first  degree,  of  severe  reddening 
with  a  burning  or  itching  sensation,  on  which  numerous  miliary 
or  submiliary  vesico-pustules  or  small  purpuric  spots  appear.  This 
eruption,  often  localized  in  the  groins,  on  the  genital  organs  and 
in  the  axillse,  sometimes  tends  to  become  diffuse  and  then  gives  the 
picture  of  cutaneous  hydrargyria  due  to  internal  causes.  A  more 
30 


466  ARTIFICIAL  DERMATITIDES 

or  less  dark  and  persistent  pigmentation  often  follows  the  mercurial 
erythema. 

Reducing  agents,  so  widely  employed  in  dermatotherapy,  are 
all  in  varying  degrees  capable  of  producing  dermatitis;  this  is 
accounted  for  by  their  special  chemical  effect,  sometimes  favored 
by  an  idiosyncrasy  of  the  patient.  Sulphur,  sulphites,  resorcin  and 
naphthol  are  usually  not  injurious  unless  employed  in  excessive 
dosage.  Pyrogallol  stains  the  epidermis  black;  it  may  produce 
erythema  with  enormous  swelling  and  even  sloughing. 

Chrysarobvn,  when  dissolved  by  the  alkaline  sweat,  gives  rise  to 
a  brown  or  purplish,  more  or  less  extensive  reddening  with  pruritus 
and  sometimes  a  pseudo-phlegmonous  infiltration  lasting  several 
weeks.  The  bronzed  erythema  of  chrysarobin  is  typical.  When 
applied  near  the  eyes,  the  remedy  causes  a  severe  conjunctivitis 
with  swelling  of  the  eyelids,  ulcerations  of  the  cornea,  etc. 

The  various  tars,  notably  oil  of  cade  may  produce  an  ordinary 
erythemato-vesicular  dermatitis.  Their  prolonged  employment 
leads  to  hyperkeratosis.  Some  individuals  moreover  develop  an 
eruption  of  folliculitis,  solid  papular  elevations  centered  by  a 
sort  of  brown  comedo,  with  ultimate  suppuration.  This  tar  acne 
develops  especially  in  hairy  regions,  particularly  on  the  legs;  it  is 
obstinate  and  lasts  several  weeks  (Fig.  123). 

Oxidizing  agents  are  relatively  slightly  injurious.  However, 
potassium  permanganate  in  strong  solution  or  as  a  powder,  very 
strong  hydrogen  peroxide  and  other  peroxides,  alter  the  horny  layer 
and  cause  redness  and  vesiculation.  Picric  acid,  recommended 
as  harmless,  is  capable  of  producing  erythema  with  edema  and 
eczematous  vesiculation,  even  when  employed  strictly  according  to 
prescription. 

Dyes  for  the  hair  and  beard  usually  have  for  their  basis  silver 
nitrate,  subacetate  of  lead  or  pyrogallic  acid;  among  their  con- 
stituents, paraphenylene-diamin  is  especially  dangerous.  A  few 
hours  after  the  first  application,  or  very  often  after  a  period  of 
complete  tolerance  extending  over  months  and  years,  an  edematous 
and  highly  pruritic  erythema  suddenly  makes  its  appearance  on 
the  upper  part  of  the  face  and  especially  on  the  eyelids;  rapidly 
extending  to  the  entire  face,  the  neck  and  sometimes  the  shoulders 
and  the  hands.  If  the  reaction  is  severe,  the  erythema  becomes 
covered  with  vesicles  which  rupture  and  are  followed  by  oozing 
and  crusts.  The  edema  usually  subsides  in  a  few  days,  but  the 
desquamation  persists  somewhat  longer.  An  acute  eczema  of  the 
regions  indicated  above,  when  the  hair  or  beard  has  been  arti- 
ficially colored,  will  be  readily  traced  to  its  true  cause. 

In  order  to  prove  that,  a  particular  substance  has  been  injurious, 
a  trace  of  the  suspected  substance  may  be  applied  on  a  Aery  small 


TOXIDERMAS  FROM  EXTERNAL  CAUSES  467 

slightly  abraded  surface  of  the  patient's  skin  and  covered  with 
gauze  and  a  plaster;  from  twelve  to  twenty-four  hours  afterward 
an  examination  will  disclose  the  presence  or  absence  of  a  dermati- 
titis.  This  "reaction  test"  thus  strictly  localized  is  devoid  of 
danger. 

The  treatment  of  the  external  drug  eruptions  comprises  in  the 
first  place  the  removal  of  the  injurious  substance,  if  traces  of  it 
persist.  When  possible,  the  employment  of  this  substance  and 
even  of  analogous  products  must  thereafter  be  strictly  avoided. 
Next,  dressings  appropriate  to  the  degree  and  seat  of  the  lesion 
may  be  applied,  lotions,  sprays,  powders,  soothing  applications, 
as  indicated  in  the  treatment  of  erythemas,  eczemas,  etc. 

Internal  treatment  with  calcium  salts  or  ichthyol  has  sometimes 
seemed  to  be  of  some  value  in  my  experience. 

B.  Induced  Dermatitides. — In  this  paragraph  will  be  considered 
the  cutaneous  irritations  and  lesions  produced  intentionally  or 
otherwise  by  the  physician,  for  therapeutic  purposes.  Skin  lesions 
voluntarily  produced  by  the  patient  with  a  view  to  malingering 
will  be  discussed  separately  (§E). 

Everyone  is  familiar  with  the  reactions  caused  by  the  customary 
counter-irritants,  rubefacients  and  vesicants,  such  as:  mustard 
plaster,  hot  water,  chloroform,  spirits  of  turpentine,,  ammonia, 
ethyl  and  methyl  chlorides,  tincture  of  iodin,  iodized  and  analogous 
cotton,  cantharides  plaster  or  tincture,  etc. 

It  is  noteworthy  that  their  application  leaves  in  some  individuals 
a  very  undesirable  and  persistent  pigmentation;  this  excessive  or 
prolonged  action  may  cause  sloughs,  badly  healing  ulcers,  etc., 
especially  in  children  and  persons  with  a  delicate  skin.  Old  iodin 
tincture  contains  hydriodic  acid  and  becomes  caustic.  The  vesico- 
pustules  caused  by  thapsia,  croton  oil  and  tartrate  of  antimony 
are  often  followed  by  cicatrices,  so  that  these  substances  should  be 
employed  very  carefully. 

As  soon  as  the  epidermis  is  damaged  there  is  an  open  avenue  for 
pyococcic  infections  and  all  aseptic  precautions  must  therefore  be 
taken  before  employing  a  strong  counter-irritant;  moreover,  clean 
dressings  must  be  applied  after  it  has  done  its  work. 

Subcutaneous  injections  of  camphorated  oil  sometimes  and 
injections  of  paraffin  for  cosmetic  purposes  very  frequently  leave 
intradermic  or  hypodermic  nodules  which  have  been  discussed 
elsewhere  in  this  book  (p.  276). 

C.  Occupational  Dermatitides. — These  comprise  a  great  variety 
of  eruptions  ranging  from  acute  erythema,  or  lichenoid  thickening 
of  the  skin  with  cracks,  to  the  different  degrees  of  burns. 

Eczema  known  as  occupational  eczema  is  especially  common  (Fig. 
144),  and  pyodermatitides,  in  the  form  of  impetigo,  folliculitis, 
lymphangitis,  etc.,  occur. 


1 1  is 


ARTIFICIAL   DERMATITIDES 


The  seat  of  the  occupational  eruptions  depends  upon  the  region 
exposed  to  the  injurious  contacts. 

The  lesions  therefore  begin  preeminently  on  the  hands,  more 
particularly  their  dorsal  surface  or  still  more  often  in  the  inter- 
digital  spaces;  the  nails  in  the  prolonged  forms  are  often  worn, 
detached  or  grooved,  fissured   and   dotted.     Next,  the  wrists  and 

forearms  are  invaded.  The  face 
and  neck  are  affected  primarily  or 
secondarily.  The  covered  parts, 
the  scrotum,  groins  and  axillae 
are  damaged  in  those  cases  where 
the  clothes  are  impregnated  with 
irritating  dust,  gases  or  fluids. 

The  course  varies  according  to 
the  cause,  form  and  degree  of  the 
eruption  as  well  as  the  individual 
conditions  in  a  given  case.  Occu- 
pational eczemas  may  become  per- 
manently established  and  recur 
incessantly,  behaving  as  if  the 
chemical  traumatism  had  been 
only  the  determining  cause  of  the 
onset  of  a  diathetic  eczema. 

What  has  been  said  about  the 
drug-eruptions  permits  me  to  be 
brief  in  regard  to  the  eruptions  of 
workers  with  chemical  products 
(quinin,  etc.),  photographers  (al- 
kalies and  reducing  agents,  amido- 
phenol, metol,  etc.)  and  operating 
surgeons;  in  the  latter,  the  fre- 
quent scrubbing  and  washingwith 
soap  predispose  to  the  injurious 
action  of  the  various  antiseptics. 
Washerwomen,  cooks  and  dish- 

, .  .         washers  usually  have  a   smooth, 

lie   144.— Occupational  eczema  01  ...  .        K  ..  .,,       , 

washerwomen.  sliming,  red  and     parqueted    pal- 

mar skin;  the  excessive  employ- 
ment of  potash  soap,  washing-soda  and  Javelle  water,  is  here  very 
apt  to  induce  an  artificial  eczema  with  a  topographical  distribution 
on  the  hands  and  fingers,  as  stated  above. 

Bricklayers  and  plasterers  have  in  the  same  regions  a  thickened 
sometimes  fissured  epidermis  and  are  subject  to  eczematization  of 
the  fingers,  hands  and  wrists,  with  pyodermatitis  and  lymphangitis; 
the  handling  of  the  various  cements  seems  to  be  the  essential  cause. 


TOXIDERMAS  FROM  EXTERNAL  CAUSES  469 

Grocers  handle  a  mass  of  irritative  substances  and  sometimes 
present,  especially  in  the  cold  season  of  the  year,  eczematiform  or 
lichenoid  lesions  complicated  by  edema  and  fissures,  which  have 
been  designated  as  'grocers'  itch";  this  term  is  fairly  characteristic 
for  the  seat  and  gross  appearance  of  this  eruption. 

Cabinet-makers,  painters  and  workmen  who  use  varnishes,,  essen- 
tial oils,  especially  spirit  of  turpentine,  are  exposed  to  erythemato- 
vesicular  and  edematous  eruptions  bearing  a  close  resemblance  to 
acute  eczema  or  dysidrosis  as  well  as  to  chronic  eczemas. 

Sugar-refiners,  confectioners,  etc.,  who  are  in  constant  contact 
with  sugar,  often  suffer  from  impetigos,  whitlows  and  pyodermati- 
tides. 

There  is  finally  an  entire  series  of  occupations  in  which  the 
utilized  materials  themselves  or  their  products  give  rise  to  a  more 
or  less  ordinary  dermatitis  tending  to  secondary  infections.  It 
suffices  to  mention  in  this  connection :  the  acneiform  folliculitis,  due 
to  tar,  petroleum  and  paraffin;  the  pyodermatitis  of  curriers, 
tanners  and  knackers;  the  various  eruptions  of  mechanics,  chauf- 
feurs, etc.,  who  are  in  contact  with  impure  or  rancid  oils;  the  pruritus 
of  bakers  [bakers'  itch],  etc. 

More  specific  in  their  cause  and  manifestations,  are  the  occu- 
pational eruptions  of  workers  in  Provence  cane;1  spinners  and 
weavers  of  flax;  dressers  of  hemp;  sorters  or  binders  of  wool;  washers 
of  silkworm  cocoons;  workers  with  chlorin  (chlorin  acne);  and 
gardeners  (poisonous  plants),  etc. 

Pigeonneau,  or  rossignol2  is  an  occupational  disease  of  the  hands 
in  skin-dyers,  which  was  carefully  described  by  Brocq  and  Laubry. 
It  is  characterized  by  lenticular  ulcerations,  not  very  numerous  as 
a  rule,  occupying  the  dorsal  surface  of  the  fingers  or  the  hand;  they 
are  round  or  oval,  covered  with  an  adherent  black  imbedded  crust; 
their  border  is  raised  and  reddened;  the  ulceration  is  perpendicular 
and  deep,  with  an  irregular  floor.  The  affection  is  very  painful 
and  heals  rather  slowly. 

Treatment. — When  dealing  with  an  occupational  dermatitis,  the 
first  thing  to  be  done  is  to  cleanse  the  parts  by  means  of  local 
baths  or  moist  detergent  dressings;  these  should  be  more  or  less 
frequently  renewed  and  continued  throughout  the  acute  stage. 
In  other  cases  the  skin  is  cleansed  with  benzin,  c6ld  cream  or  vase- 
lin.  It  is  rarely  necessary  to  resort  to  chemical  neutralization  or 
solvents,  which  are  sometimes  dangerous  in  themselves.  Topical 
medication  is  governed  as  usual  by  the  lesion  (erythema,  burn, 
eczematization  or  pyodermatitis)  and  not  by  the  cause. 

General  treatment  and  especially  hygienic  rules  must  not  be 
neglected. 

1  [A  reed  used  for  thatch-roofs.] 

2  [Young  pigeon  and  nightingale  respectively;  popular  names  for  this  dermatosis.] 


1,11  AkTlPlClAL   DEllMATITIDKS 

The  difficulty  in  regard  to  occupational  eruptions  consists  in 
the  prevention  of  recurrences.     Often,  by  utilizing  precautionary 

measures  and  cleanliness,  with  protection  of  the  exposed  regions 
and  attention  to  hygiene,  the  patient  can  resume  his  occupation 
and  avoid  the  trouble  which  threatens  him  more  seriously  after 
the  first  attack.  Sometimes,  when  there  is  an  evident,  well- 
marked  and  persistent  predisposition,  a  change  of  employment  or 
occupation  becomes  imperative.  It  is  readily  appreciated  that  the 
physician  may  find  himself  in  a  difficult  position  in  cases  of  this 
kind. 

D.  Dermatitis  Venenata. — Numerous  indigenous  or  exotic 
'plants  are  capable  of  producing  by  contact,  not  only  a  transitory 
urticaria  like  that  caused  for  instance  by  nettles,  but  prolonged 
eruptions,  especially  of  an  erythemato-vesicular  or  bullous  type, 
with  edema,  severe  itching  and  sometimes  fever. 

The  eruption  appears  soon  after  the  contact;  it  may  extend  and 
become  generalized.  When  the  patient's  occupation  or  the  data 
furnished  by  him  do  not  suggest  the  cause,  one  may  mistake  the 
etiology  of  the  condition  which  may  thereupon  become  obstinate 
and  recurrent.  A  considerable  number  of  seasonal  eruptions  of 
the  hands  and  face  are  of  plant  origin;  this  must  be  kept  in  mind  and 
inquiries  in  this  direction  must  be  made. 

Among  the  poisonous  plants  which  are  most  frequently  respons- 
ible mention  may  be  made  of:  daphne  mezereum,  several  euphor- 
bias, rhus  toxicodendron  (poison  ivy)  and  several  related  species, 
primula  obconica  (primrose),  and  a  few  analogous  hothouse  plants, 
arnica  montana,  clematis,  colchicum,  scilla,  thuya,  some  chrysan- 
themums, etc. 

There  also  occurs  occupational  eruptions  of  vegetable  origin,  due 
to  flax,  cinchona,  vanilla,  bitter  orange,  satin  [and  other  kinds  of 
hard]  wood,  etc. 

Many  animals,  of  different  species,  not  counting  the  parasites 
which  will  be  discussed  further  on  (Chapter  XXIV)  may  give  rise 
to  eruptions  through  contact  with  them.  Such  are  the  medusa?, 
actinia,  processional  caterpillars  [brown-tail  moth],  and  a  few  others 
cantharides,  etc. 

Others  have  a  poisonous  sting,  notably  scorpions  and  many  of 
the  hymenoptera — bees,  wasps,  hornets,  bumble-bees,  etc.  On 
being  stung  by  one  of  these  insects,  an  extremely  severe  pain  is 
immediately  felt  and  is  promptly  followed  by  urticarial  redness 
with  considerable  edema;  finally  a  bullous  or  vesicular  eruption 
may  develop,  on  the  same  spot  or  at  a  distance.  A  sting  on  the 
tongue  or  pharynx  has  been  known  to  cause  death.  But  aside 
from  cases  of  this  kind,  alarming  symptoms  are  sometimes  observed, 
cither  on  account  of  multiple  stings  or  perhaps  due  to  the  effect  of 


TOXIDERMAS  FROM  INTERNAL  CAUSES  471 

direct  penetration  of  the  poison  into  a  vein  or  to  a  special  sus- 
ceptibility. The  venom  of  the  hymenoptera,  studied  by  Phisalix 
and  by  Calmette,  is  analogous  to  the  venom  of  serpents.  It  may 
cause  vertigo,  vomiting,  respiratory  disturbance,  weak  pulse,  fever, 
cold  sweats,  syncope  and  convulsions.  Usually  the  disturbance 
passes  off  in  a  few  days. 

The  treatment  of  eruptions  due  to  contact  with  plants  and  animals 
consists  in  the  removal  of  the  cause  and  in  dressing  the  lesions 
according  to  the  type  of  eruption. 

Against  the  stings  of  venomous  insects  may  be  recommended 
strong  salt  water,  dilute  ammonia,  a  solution  of  permanganate  and 
rubbing  with  various  fresh  herbs,  especially  with  parsley.  In  the 
first  place  it  must  be  ascertained  if  the  sting  has  remained  in  the 
wound  and  if  this  is  the  case,  it  must  be  extracted.  Calmette  has 
obtained  excellent  results  from  applications  of  calcium  hypochlorite 
1  to  60  or  Javelle  water  1  to  100. 

E.  Simulated  Dermatitides  [Feigned  Eruptions]. — These  are 
observed  among  beggars,  prisoners,  soldiers  and  in  hysterical 
individuals.  Medicinal  substances  (see  induced  dermatitides),  or 
poisonous  plants,  or  sometimes  burns,  are  especially  utilized  by 
malingerers  for  the  purpose  of  producing  eruptions  intended  to 
excite  compassion,  to  avoid  a  tedious  service,  or  to  make  the  subject 
interesting.  The  procedure  varies  according  to  the  intellectual 
standard  of  the  individual  and  his  opportunities  for  securing  the 
necessary  materials. 

The  lesions  extend  from  a  simple  discoloration  of  the  epidermis 
to  eczematoid,  erysipeloid  and  pemphigoid  eruptions  and  even 
sloughing.  Their  configuration,  arrangement  and  course  naturally 
defy  a  general  description.  It  is  often  their  bizarre  appearance 
that  attracts  attention;  their  angular  or  geometrical  forms  are  apt 
to  betray  their  origin;  sometimes  a  trace  of  the  material  which  has 
been  used  is  discovered.  It  should  be  kept  in  mind  that  sycosis 
is  relatively  easily  induced. 

The  seat  of  the  lesions  is  always  accessible  to  the  hand  of  the 
patient.  Inquiry  and  investigation  frequently  fail,  the  patient 
keeping  up  his  denial  in  the  face  of  the  unmistakable  evidence. 
Immovable  occlusive  dressings  naturally  suppress  the  pathological 
manifestations  or  cause  them  to  shift  their  place.  Unless  the 
patient  can  be  made  to  see  the  error  of  his  ways  and  unless  he  con- 
sents to  be  cured,  recurrences  are  apt  to  be  indefinitely  prolonged. 

TOXIDERMAS   FROM   INTERNAL   CAUSES. 

These  may  be  grouped  under  medicinal  toxidermas,  serum  toxi- 
dermas,  alimentary  toxidermas  and  autotoxic  eruptions. 


472  ARTIFICIAL   DERMATITIDES 

A.  Medicinal  and  Toxic  Eruptions  of  Internal  Origin.— It  is 
impossible  to  make  ;i  complete  list  of  all  medicinal  substances  and 
poisons  capable  of  producing  eruptions.  Some  react  rather  fre- 
quently upon  the  skin;  with  others,  tins  accessory  effect  is  excep- 
tional. 

It  is  not  so  much  the  mode  of  absorption,  the  dose  or  the  im- 
purities in  the  remedy  which  must  he  held  responsible  as  it  is  the 
idiosyncrasy  of  the  subject. 

The  form  of  the  eruption  varies  not  only  with  the  substance  but 
also  with  the  individual. 

I  shall  restrict  myself  to  a  rapid  enumeration  of  the  ordinary 
eruptions  and  their  most  common  causes  and  follow  with  a 
description  of  the  more  characteristic  special  eruptions. 

Erythema  in  patches,  urticarial  erythema  and  medicamentous 
roseola  represent  the  most  common  eruptions.  The  eruption  is 
situated  on  the  trunk,  on  the  face  and  on  the  inner  surface  of  the 
limbs;  it  is  more  or  less  abundant  and  extensive;  it  is  sometimes 
scaly  and  often  very  pruritic.  It  may  be  accompanied  by  enanthema, 
conjunctiva]  congestion,  erythematous  angina,  but  not  by  laryngo- 
tracheo-bronchitis  as  in  measles.    Fever  and  diarrhea  are  rare. 

The  eruption  appears  at  a  variable  time,  often  very  soon  after 
absorption.  It  may  develop  in  attacks  or  extend  progressively; 
it  attains  its  height  in  two  or  three  days.  It  is  not  rare  for  the 
patches  of  a  more  or  less  urticarial  erythema  to  spread  after  the 
fashion  of  an  oil-spot  while  the  center  recovers  or  heals,  resulting  in 
marginate  or  circinate  forms.  In  a  few  days,  the  eruption  dis- 
appears without  desquamation  and  without  leaving  maculae. 

Toxidermic  erythemas  are  due  especially  to  the  following  sub- 
stances: quinin,  antipyrine,  morphin,  the  balsams,  terpene,  chloral, 
iodides,  bromides,  digitalis,  salicylic,  boric  and  benzoic  acids, 
antimony,  arsenic,  exalgine,  etc.  In  a  soldier  who  had  been  exposed 
to  the  action  of  asphyxiating  gases,  I  observed  a  marginate  erup- 
tion of  urticarial  erythema,  recurring  for  over  eight  months. 

Scarlatinoid  erythema  is  less  common;  it  occupies  especially  the 
flanks,  the  great  articular  folds  and  may  spread  over  the  entire 
body,  persist  several  days  and  be  associated  with  a  more  or  less 
marked  and  prolonged  lamellar  desquamation;  the  clinical  picture 
Mill  then  be  that  of  a  primary  acute  erythroderma  (Chapter  VI). 
Recurrences  arc  not  uncommon.  This  form  is  observed  especially 
after  the  administration  of  mercurials,  quinin,  chloral,  opium,  mix 
vomica,  belladonna,  salicylic  acid,  ipecac,  antipyrin,  sulfonal, 
benzoates,  etc. 

Urticaria  fChapter  II),  as  common  as  the  erythemas  with  which 
it  is  often  combined,  may  be  caused  by  the  balsams,  quinin,  mor- 
phin, hyoscyamus,  antipyrin,  arsenic,  iodides,  bromides,  chloral, 
santonin,  etc. 


TOXIDERMAS  FROM  INTERNAL  CAUSES  4,'-', 

Purpura  is  less  frequent.  A  list  of  drugs  which  may  cause  its 
appearance  has  already  been  given  (Chapter  III). 

Bullous  eruptions  sometimes  result  from  the  absorption  of  iodides, 
bromides,  antipyrin,  arsenic,  quinin,  salicylic  acid,  antimony 
aconite,  etc.  The  appearance  is  that  of  a  bullous  erythema  (Fig. 
146),  hydroa,  or  sometimes  Duhring's  disease. 

The  same  substances  may  give  rise  to  suppurative  folliculitides, 
of  acute  or  sluggish  course. 

Strictly  speaking,  there  is  no  eczema  of  internal  medicinal  origin; 
but  an  already  present  eczema  may  become  aggravated  by  any  one 
of  the  above-mentioned  substances,  notably  by  the  iodides,  arseni- 
cals,  etc.  In  case  of  eczematosis,  numerous  medicinal  agents,  and 
also  dietetic  errors,  etc.,  are  capable  of  starting  an  attack. 

Pigmentary  spots  sometimes  originate  under  the  internal  use  of 
antipyrin,  arsenic,  blistering  gases  and  perhaps  still  other  substances. 

Gangrenes,  in  the  form  of  gangrenous  eruptions  or  gangrene  of 
the  extremities,  have  been  observed  after  absorption  of  ergot  of 
rye,  carbon  monoxide,  antipyrin,  arsenic,  iodides  and  chloral. 

Thallium  salts  produce  a  total  alopecia. 

Belladonna,  morphin,  cocain,  nux  vomica,  aconite,  etc.,  may 
cause  pruritus  without  eruption. 

It  is  obvious  that  the  cutaneous  manifestations  due  to  internal 
medicaments  are  varied  and  often  not  characteristic;  the  same 
drug  may  produce  very  different  effects.  A  suspicion  of  a  drug- 
eruption  is  created  by  its  behavior,  its  sudden  appearance,  its  poly- 
morphism, the  absence  of  symptoms  common  in  the  diseases  which 
it  simulates  and  by  its  recurrence  under  similar  conditions.  An 
inquiry,  which  must  sometimes  be  most  minute  and  searching,  will 
establish  the  correctness  of  the  suspicion  which  has  been  aroused. 
Occasionally,  if  the  patient  wishes  or  consents,  it  is  possible  to 
make  an  experimental  demonstration  of  the  diagnosis  by  adminis- 
tering a  small  dose  of  the  supposedly  harmful  drug.  It  has  been 
said  before  (page  461)  that  it  is  not  possible  in  these  cases  to 
establish  a  passive  anaphylaxis  in  animals. 

The  following  eruptions  are  less  common;  their  characters 
suffice  to  suggest  their  origin;  some  are  actually  almost  specific. 

Balsamic  Erythemas. — Copaiva,  cubebs,  santal  and  turpentine 
give  rise  to  roseolar  erythemas  or  erythematous  patches,  often 
urticarial  and  marginate,  very  pruritic,  of  a  bright  red  color, 
occurring  specially  on  the  extensor  surface  of  the  large  joints  or  on 
the  upper  part  of  the  trunk,  later  on  becoming  more  or  less  general- 
ized. Their  frequency  has  greatly  declined  since  the  less  common 
use  of  the  balsams  in  the  treatment  of  gonorrhea. 

Antipyrinides. — Antipyrin  has  already  been  mentioned  among 
the  substances  capable  of  exciting  various  erythemas,  urticaria, 


474 


ARTIFICIAL  i)h:i;\i.\TiT[Di-:s 


purpura,  etc.  Very  rarely,  the  eruption  may  simulate  syphilitic 
roseola  (A.  Fournier),  although  it  lias  a  slightly  deeper  shade  of  red 
and  is  less  persistent. 

This  remedy  also  produces  persistenl  erythemato-pigmented 
patches,  which  were  carefully  studied  by  Brocq  and  are  practically 
pathognomonic.  These  patches,  single  or  scanty  at  the  first  onset, 
more  numerous  when  the  medication  is  continued  (Fig.  14")),  are 
scattered  irregularly  and  may  he  situated  anywhere;  they  are 
round  or  oval,  nummular  or  the  size  of  the  hand,  dusky  red,  well 
outlined  and  slightly  urticarial  and  cause  a  rather  pronounced 
burning  sensation. 


i 

*  1 

1         lit                *    * 

*1 

* 

1 

If 

It 

FlG.    145. — Antipyrinide.     Remarkably    profuse  eruption  of  erythemato-pigmented 

spots. 


After  a  few  days  the  redness  subsides  and  a  fine  or  lammelar 
desquamation  ensues;  but  the  brown  or  even  black  pigmentation 
persists  and  fades  only  in  the  course  of  time.  When  the  patient 
takes  more  antipyrin,  after  several  hours  or  even  in  twenty  minutes, 
the  same  spots  again  become  congested  and  simultaneously  new 
spots  may  appear,  in  haphazard  distribution,  taking  a  similar  course. 
They  are  easily  diagnosed  from  their  circumscribed  pigmentary 
and  their  stationary  character. 

Sometimes,  a  certain  number  of  these  spots  or  patches  become 
the  seat  of  bullcB  or  vesicles-. 


TOXIDERMAS  FROM  INTERNAL   CAUSES 


475 


Cases  of  localized  edema  and  fulminating  gangrene  due  to  anti- 
pyrin  [and  affecting  the  genitals  particularly],  have  also  been 
reported.  Compounds  containing  antipyrin  (such  as  "migrainin," 
etc.),  of  course,  have  the  same  effects.  The  erythemas  produced  by 
other  analgesic  and  hypotonic  agents  are  not  so  well  known;  fairly 
numerous  but  dissimilar  observations  have  been  recorded. 

Iodides. — Potassium  iodide  and  all  other  iodides  or  iodin  com- 
pounds may  give  rise  to  diffuse  erythemas,  urticaria,  purpura,  or 
even  to  gangrene.  Nodosities  due  to  the  iodides,  analogous  to  those 
of  ervthema  nodosum  are  likewise  known  to  occur. 


Fig.   146. — Iododern 


im  of  the  neck,  occurring  a  day  after  taking  a  mixture 
containing  potassium  iodide. 


The  most  typical  iodide  or  potassium-iodide  eruption  is  iodide 
pemphigus,  which  has  been  mentioned  before  (p.  177)  and  would  be 
better  described,  according  to  its  appearance,  as  bullous  (Fig.  146), 
ecthymatous,  or  fungoid  iodide  eruption.  When  the  administration 
of  the  remedy  is  continued,  the  lesions  become  ulcero- vegetative, 
increase  in  size  and  often  invade  the  mucous  membranes;  they  are 
accompanied  by  general  disturbances,  diarrhea,  albuminuria  and 
cachexia  and  may  cause  actual  mutilations  or  death  itself. 

Iodide  acne  is  very  common  and  develops  almost  exclusively  in 
kerotic   individuals;    it  affects  the  same  areas    as    acne  vulgaris, 


176  ARTIFICIAL  DERMATITIDES 

from  which  it  differs  only  in  the  more  inflammatory  character  and 
the  greater  size  of  the  papulo-pustules,  their  dark  red  color  and  their 
deep  induration.  Sonic  lesions  may  be  distinctly  anthracoid 
!  iododerma  tuberosum  I. 

Bromides.  The  most  specific  eruptions  are  produced  by  potas- 
sium bromide,  more  frequently  than  by  other  bromin  compounds 
usually  after  the  large  and  prolonged  doses  prescribed,  for  instance, 
in  epilepsy. 

Bromide  acne  is  like  iodide  acne;  the  ecthymatous  and  fungoid 
bromide  eruptions  resemble  iodide  eruptions  of  the  same  type. 

Fungoid  papulo-tubercular  bromide  eruptions  are  less  common. 
but  are  pathognomonic  (bromoderma  tuberosum).  It  consists  of  a 
nummular  or  more  extensive  prominence,  with  a  crusted  mammil- 
lated  or  papillomatous  surface,  of  a  purplish  red  color  and  peculiarly 
soft  quality,  giving  the  sensation  of  wet  velvet  to  the  touch.  The 
distinctly  outlined  patch  is  bordered  by  a  margin  of  sub-epidermic 
suppuration;  it  enlarges  by  several  millimeters  daily  and  becomes 
confluent  with  neighboring  lesions.  The  fungoid  bromide  eruptions 
occur  chiefly  on  the  face  and  especially  the  nose  though  often  on 
the  legs  (most  frequently  in  my  experience]  or  the  buttocks,  but  they 
may  also  be  met  with  in  other  regions. 

Their  softness  and  rapid  course  distinguish  them  from  papillo- 
matous or  fungoid  tuberculosis,  fungoid  syphilides  and  pemphigus 
vegetans.  Pasini  interprets  the  cutaneous  lesions  as  due  to  bromin 
liberated  in  the  stomach  under  the  influence  of  hypochlorhydria. 

Hydrargyria. — Mercury  and  all  its  compounds  without  exception, 
whether  absorbed  by  the  gastric  route,  inhaled  in  form  of  mercurial 
vapors,  injected  into  the  mucous  cavities,  veins  or  subcutaneous 
tissues,  may  occasion  an  attack  of  cutaneous  hydrargyria;  infinitely 
small  doses  sufficing  in  the  presence  of  a  special  idiosyncrasy. 
Hydrargyria  through  external  applications  is  relatively  frequent; 
through  ingestion  or  injection  it  is  very  rare  in  proportion  to  the 
large  number  of  patients  to  whom  mercury  is  administered.  It  is 
advisable,  however,  to  keep  this  possibility  in  mind. 

Alley  and  Bazin  have  described  three  degrees  of  hydrargyria: 

In  the  benign  forms  the  trouble  is  limited  to  a  localized  redness 
with  a  few  small  vesicles,  especially  in  the  groins  and  on  the  inner 
surface  of  the  thighs. 

In  the  moderate  form,  there  is  a  severe  erythema  occupying  the 
large  folds,  the  groins,  the  axillae  as  well  as  the  palmar  and  plantar 
regions;  the  red  surface,  sometimes  dotted  with  hemorrhagic  points, 
becomes  covered  with  an  abundant  crop  of  small  vesicopustules 
resembling  miliaria  alba.  There  is  an  intolerable  itching  and  burn- 
ing sensation;  fever,  digestive  disturbances  and  albuminuria  may 
be  present.     The  crusts  are  followed  by  oozing,  then  by  a  more  or 


TOXIDERMAS  FROM  INTERNAL  CAUSES  477 

less  persistent  lamellar  desquamation  (see  Fig.  143).  The  clinical 
picture  may  be  exactly  that  of  an  acute  or  subacute  primary  erythro- 
derma; upon  occurrence  of  this  eruption,  hydrargyria  should 
always  be  suspected. 

The  malignant  form  is  accompanied  by  swelling  of  the  face  and 
the  extremities,  by  large  bullae,  pyodermatitides,  abscesses,  adenitis, 
angina  and  gangrene  and  may  lead  to  death.  Desquamation  occurs 
in  large  shreds.  It  is  noteworthy  that  in  cases  of  cutaneous  hydrar- 
gyria, mercurial  stomatitis,  colitis,  etc.,  are  not  infrequently  absent. 

Arsenic. — Aside  from  the  ulcerations  of  the  skin  and  mucous 
membranes  observed  in  occupational  arsenic  poisoning,  the  adminis- 
tration of  arsenic  as  a  remedy  gives  rise  especially  in  the  palmar  and 
plantar  regions,  but  also  elsewhere,  to  erythemas,  urticaria,  purpura, 
bullae,  etc.  The  frequency  of  zona  in  patients  who  take  arsenic  has 
been  noted.  Injections  of  the  arsenobenzols  are  followed,  in  rare 
instances,  by  more  or  less  generalized  eruptions  of  erythematous 
spots;  even  scarlatiniform  erythemas  have  been  reported. 

Pigmentations,  in  spots  or  diffuse,  as  well  as  arsenical  keratoses 
are  more  typical;  I  have  seen  the  latter,  associated  with  a  dystrophic 
condition  closely  suggesting  xeroderma  pigmentosum  or  senile 
degeneration,  give  rise  to  multiple  epitheliomas,  the  so-called  arsenical 
cancer. 

Treatment. — In  the  presence  of  a  medicinal  toxiderma  of  any 
kind,  the  essential  point  is  the  discovery  of  the  injurious  substance 
and  the  avoidance  of  its  use.  When  its  employment  is  absolutely 
required  [as  with  arsenobenzol  in  syphilis]  it  should  only  be  after  a 
long  interval,  beginning  cautiously  with  small  doses,  and  [if  possible] 
varying  the  form  and  mode  of  administration  of  the  remedial  agent. 
Rest,  a  laxative,  abundant  drinks,  especially  milk  mixed  with 
Vichy  or  Vals  water  and  large  enemas,  may  prove  useful. 

Some  medicinal  eruptions  (bromides,  arsenic,  mercury)  persist  a 
really  long  time  after  the  responsible  medication  has  been  stopped 
and  one  must  be  prepared  for  this.  The  employment  of  corrective 
compounds  or  of  so-called  antidotes  is  not  to  be  recommended. 
The  cutaneous  lesions  should  be  treated  [symptomatically]  accord- 
ing to  the  form  of  the  eruption.  Against  the  general  symptoms  of 
iodism,  Milian  has  recently  recommended  adrenalin. 

B.  Serum  Eruptions. — The  disturbances  which  have  been 
observed  since  the  therapeutic  employment  of  antitoxic  sera 
(antidiphtheritic,  antitetanic,  antimeningococcic  sera)  were  first 
attributed  to  the  antitoxins,  but  are  now  known  to  be  due  to  the 
vehicle,  usually  horse  serum  and  may  be  produced  by  any  foreign 
serum.  The  contributions  of  Arthus  and  von  Pirquet,  the  clinical 
studies  of  Marfan,  Weil-Halle  and  Lemaire,  among  others,  have 
helped  to  elucidate  the  relations  existing  between  "serum  sickness" 
and  anaphylaxis, 


178  ARTIFICIAL  DEItM  ATI  TIDES 

True  scrum  symptoms,  namely  those  occurring  after  the  first 
injection,  arc  rather  rare,  being  observed  in  only  14  per  cent,  of  the 
ease-,  according  to  L.  Martin.  They  may  appear  very  soon,  or  more 
frequently  after  an  incubation  of  ten  to  fifteen  days  and  generally 
consist  of  urticaria  or  a  marginate  ephemeral  erythema,  preferably 
localized  in  the  vicinity  of  the  injection,  or  disseminated. 

When  another  injection  of  serum  is  administered  a  long  time  (at 
least  fifteen  days,  but  even  several  years)  after  the  first,  the  onset  of 
anaphylactic  symptoms  is  frequently  seen  (in  50  per  cent,  of  the 
cases),  developing  either  immediately  or  after  four  or  five  hours  or 
sometimes  after  two  to  ten  days. 

The  symptoms  developing  promptly  consist  of  anxiety,  dyspnea, 
weak  pulse  and  vomiting;  they  are  controlled  by  injections  of 
adrenalin. 

The  more  delayed  disturbances  manifest  themselves  under  two 
type-,  which   are  often   associated: 

1.  A  local  reaction,  an  erysipeloid  or  pseudo-phlegmonous  redness 
with  glandular  swelling,  lasting  from  two  to  four  days.  Marfan  calls 
this  the  "  Arthus  phenomenon." 

2.  A  general  reaction,  a  more  or  less  profuse  eruption  of  urticaria, 
with  swelling  of  the  face,  or  a  marginate  erythema  with  extensive 
policy clic  patches,  accompanied  by  edema,  sometimes  by  anemia, 
subieterus,  purpura,  general  prostration,  very  painful  arthralgias 
and  a  fever  up  to  38°  or  39°  C.  [101°-102°  F.],  lasting  twenty-four 
or  forty-eight  hours.  These  clinical  symptoms  are  associated  with 
somewhat  variable  hematological  disturbances;  leukopenia  or 
leukocytosis,  mononucleosis,  presence  of  precipitins,  sometimes  of 
hemolysins,  delayed  coagulation,  etc. 

In  order  to  avoid  as  far  as  possible  the  necessity  for  repeated 
injections  in  the  course  of  a  disease  which  requires  serotherapeutic 
treatment,  it  is  advisable  to  employ  the  scrum  freely  and  repeatedly 
within  the  first  few  days.  But  the  fear  of  serum  accidents  should 
in  no  case  cause  the  abandonment  of  a  re-injection  when  this  is 
demanded  by  the  nature  and  course  of  the  infection;  this  at  least 
is  the  rule  laid  down  by  the  most  competent  authorities. 

All  efforts  should  be  made  to  avoid  and  control  these  symptoms. 
The  best  precaution  consists  in  administering  the  re-injection 
very  slowly,  carefully  watching  the  patient.  Except  in  extremely 
urgent  cases,  it  is  even  preferable  to  employ  successive  injec- 
tions with  small  doses  according  to  Besredka's  method.  Begin 
by  slowly  injecting  1  c.C.  of  serum  under  the  skin;  one  hour  later, 
inject  2  c.C.;  finally,  after  another  interval,  the  total  amount  of  the 
dose  is  injected.  Calcium  chloride,  in  daily  doses  of  1  to  .'!  grams, 
also  possesses,  as  shown  by  Netter,  a  distinct  preventive  action;  it 
diminishes  by  three-fourths  the  number  of  eruption  cases  among 


TOXIDERMAS  FROM  INTERNAL  CAUSES  479 

re-injected  patients  and  has  besides  a  curative  value.  Flandin, 
Martin  and  Darre,  etc.,  have  experimentally  studied  the  serotherapy 
of  serum  symptoms  endeavoring  to  produce  an  immunization  by 
means  of  repeated  injections  of  very  minute  doses,  constituting  a 
curative  anti-anaphylaxis.     Their  results  are  inconstant. 

C.  Alimentary  Eruptions. — In  the  case  of  an  eruption  occurring 
after  the  ingestion  of  a  given  food  or  drink,  it  is  often  very  difficult  to 
ascertain  how  far  the  symptoms  are  referable  to  the  real  toxicity 
of  the  suspected  substance,  the  idiosyncrasy  of  the  patient,  or  the 
auto-intoxications  revealed  on  this  occasion. 

Any  food  or  drink  the  ingestion  of  which  is  usually  forbidden  to 
persons  suffering  from  urticaria,  pruritus  and  eczema,  for  instance, 
may  accidentally  give  rise  to  an  acute  eruption  or  increase  a  pre- 
existing dermatosis  in  predisposed  individuals.  (See  Therapeutic 
notes,  §12.) 

The  following  may  be  considered  as  toxic,  that  is  injurious,  for 
most  people:  spoiled  meats  or  fish,  especially  pork;  very  high 
game;  certain  meat  extracts;  spoiled  or  diseased  mussels;  edible 
mushrooms  which  have  begun  to  putrefy,  etc. 

The  eruption  usually  follows  closely  on  the  ingestion  and  lasts  a 
very  variable  time.  It  consists  of  urticaria  of  all  kinds,  urticarial, 
scarlatinoid  or  polymorphous  erythema,  purpura  and  bullae. 

General  disturbances,  more  or  less  pronounced  or  serious,  are  its 
usual  accompaniments  in  the  form  of  fever,  vomiting,  choleriform 
diarrhea  and  various  nervous  disturbances. 

The  treatment  must  aim  primarily  at  emptying  the  digestive 
tract  through  all  means  at  our  command. 

The  patient  must  then  be  placed  on  a  strict  diet,  or  better  a  milk 
diet,  for  some  time  to  come.  The  nervous  symptoms  are  counter- 
acted by  symptomatic  treatment  and  the  same  applies  also  to  the 
cutaneous  manifestations. 

D.  Autotoxic  Eruptions. — Although  these  are  not  artificial  erup- 
tions, they  may  be  considered  as  toxidermas  and  accordingly  may 
be  discussed  in  this  chapter. 

At  the  present  day,  a  general  description  of  the  cutaneous  mani- 
festations of  arthritism  would  be  out  of  date;  although  some  authors 
try  to  substitute  chronic  auto-intoxication  for  the  vague  term 
diathesis  implied  in  this  concept,  the  so-called  arthritides  of  Bazin 
are  now  only  of  historical  interest. 

It  is  equally  impracticable  to  draw  a  picture  of  the  cutaneous 
manifestations  of  gout,  uremia  or  urinary  insufficiency,  hepatic 
insufficiency,  cholemia,  the  gastro-intestinal  dyspepsias,  etc.;  an 
attempt  of  this  kind  would  be  blocked  by  too  much  that  is  unknown. 
In  discussing  the  erythemas,  urticarias,  purpuras,  eczemas,  lichens, 
pruritus  and  prurigos,  acnes,  etc.,  what  little  is  known  of  the  relation 


180  ARTIFICIAL   DERMATITIDES 

of  these  dermatoses  to  general  nutritional  disturbances  lias  been 
mentioned.  I  repeat  that  eczematosis  of  adult  or  aged  individuals 
may  not  infrequently  lead  to  the  discovery  of  a  still  latent  internal 
cancer,  an  existing  pyelonephritis  or  nephritis,  etc. 

It  is  only  the  eruptions  of  diabetics,  the  so-called  "diabetides" 
of  A.  Fournier,  that  admit  of  a  more  or  less  general  review. 

Diabetic  Eruptions.  These  are  of  two  kinds:  Some  might  he 
considered  as  internal  toxidermas,  dependent  solely  on  the  altered 
organic  environment;  these  include  pruritus,  chronic  urticaria, 
eczema,  purpura,  gangrenes  and  xanthoma.  Others  require  in 
addition  the  intervention  of  an  external  factor,  such  as  the  pyococcic 
infection  in  the  case  of  impetigo,  ecthyma,  folliculitis,  furuncles  or 
carbuncle;  irritation  through  the  sugar  in  the  urine,  in  the  case  of 
genital  diabetides.  The  latter  alone  require  discussion.  They  may 
constitute  the  first  symptom  to  arouse  attention  and  lead  to  the 
diagnosis  of  glycosuria.  In  the  absence  of  the  necessary  cleanliness, 
especially  in  women,  the  sugar-containing  urine  on  soiling  the  skin 
irritates  the  epidermis  and  creates  an  excellent  culture-medium  for 
the  yeasts  and  the  microbes  of  suppuration.  These  women  will 
accordingly  develop  pruritus,  chronic  erythema,  or  an  often  very 
red,  edematous  and  oozing  eczema,  with  sharp  sinuous  outlines, 
marked  by  a  raised  horny  border  or  a  crop  of  pustules,  with  an 
acute,  obstinate  or  relapsing  course.  This  diabetic  eczema  of  the 
vulva  often  extends  to  the  thighs,  the  perineum,  the  groins  and  the 
abdomen.  In  diabetic  men,  the  glans  and  especially  the  prepuce 
are  often  red,  swollen,  chapped  and  eroded;  the  preputial  orifice 
finally  presents  a  fibrous  induration,  with  retraction  and  radiating 
fissures,  or  even  with  complete  phimosis.  These  various  lesions 
sometimes  reveal  the  presence  of  diabetes  mellitus. 

In  both  sexes  the  clinical  picture  may  become  complicated  by 
erysipelas  or  gangrene. 

The  treatment  must  aim  at  diminishing  the  glycosuria  through 
diet,  hygiene  and  if  necessary  by  means  of  antipyrine  or  its  ana- 
logues. Absolute  cleanliness  must  be  maintained;  with  frequent 
application  of  alkaline,  weakly  antiseptic  or  astringent  lotions 
and  bland  powders.  Painting  with  a  1  per  cent,  solution  of  silver 
nitrate  is  often  useful.  Circumcision  should  be  avoided  if  it  be 
possible,  for  it  is  not  devoid  of  danger  in  these  conditions.  A  "  cure" 
at  the  Vichy  [or  other  alkaline]  springs  is  indicated. 


CHAPTER   XXIV. 
NEURODERMATOSES;  PRURITUS  AND  PRURIGO. 

Pruritus,  or  itching,  is  a  peculiar  sensation  which  induces  scratch- 
ing; it  is  as  incapable  of  definition  as  is  a  gustatory  or  a  tactile 
sensation.  It  is  irrelevant  whether  this  sensation,  in  different  cases, 
be  compared  to  prickling,  tickling,  tingling,  the  crawling  of  an 
insect,  etc.;  the  word  itching  includes  all  these  varieties  and  is 
understood  by  everybody. 

The  finer  pathogenesis  of  pruritus  is  entirely  obscure.  In  order  to 
interpret  the  dissociations  of  sensibility  observed  in  certain  diseases, 
physiologists  have  been  led  to  suspect  the  existence  of  special  organs, 
nerves  or  nerve-terminals,  for  the  different  forms  of  sensibility,  some 
of  which  manifest  themselves  only  on  the  skin  and  on  the  neighbor- 
ing mucous  membranes:  touch,  pressure,  pain,  heat  and  cold.  It 
has  been  surmised  that  this  may  be  true  of  pruritus  also,  but  neither 
anatomy  nor  experimentation  has  confirmed  this  theory. 

In  all  probability  this  mode  of  sensation  is  dependent  on  the 
ordinary  sensory  nerves,  although  it  has  been  attributed  by  Jacquet 
to  the  sympathetic  nerves. 

Itching  results  in  different  cases  either  from  a  special  property  of 
the  irritant:  artificial  pruritus ;  or  from  cutaneous  lesions  of  various 
kinds:  secondary  pruritus;  or  from  a  special  tendency  of  the  indi- 
vidual, sometimes  occasioned  by  local  factors:  primary  pruritus. 
Frequently  several  of  these  conditions  exist  in  combination. 

The  practically  inevitable  consequence  of  itching  is  scratching. 
When  the  latter  leaves  the  skin  intact  or  produces  only  very  ordinary 
traumatic  lesions,  even  when  more  or  less  complicated  by  secondary 
infections,  the  existing  dermatosis  is  described  as  pruritus,  adding 
to  this  term  some  qualification  suggestive  of  the  pathogenesis  or 
clinical  variety  of  the  pruritus.  However,  when  the  scratching 
gives  rise  to  certain  special  reactions  in  the  skin  (papules  of  stroph- 
ulus, of  prurigo,  or  lichenization),  the  dermatosis  receives  the  name 
of  prurigo,  of  which  also  several  varieties  are  recognized. 

The  distinction  between  pruritus  and  prurigo  rests  accordingly, 
in  my  opinion,  upon  a  morphological  and  directly  demonstrable 
fact,  namely  the  presence  or  absence  of  the  peculiar  papules  which 
I  have  previously  discussed  (Chapter  VII)  or  of  lichenization.  It  is 
really  of  small  importance,  for  it  is  not  uncommon  to  find  a  pruritus 
becoming  transformed  into  a  prurigo  after  a  certain  time. 
31 


482         NEURODERMATOSES— PRURITUS  AND  PRURIGO 

Under  the  special  name  of  neurodermatoses  are  grouped  pruritus 
and  the  prurigos  which  are  neither  artificial  nor  secondary,  in  which 
the  itching  appears  as  if  primary  and  essential;  it  is  dependent  on 
a  nervous  disturbance  of  unknown  character  directly  causative  of 
the  cutaneous  manifestations. 

Artificial  Pruritus. — It  is  a  matter  of  common  knowledge  that 
certain  irritants  of  the  skin  possess  pruritic  properties  in  them- 
selves. The  crawling  on  the  skin  or  the  bites  of  parasites  such  as 
lice,  bed-bugs,  fleas,  itch  mites,  oxyuris,  the  stings  of  the  hairs  of 
mttles  or  of  the  processional  caterpillar,  the  application  of  a  large 
number  of  substances  of  vegetable,  animal  or  chemical  origin  give 
rise  to  more  or  less  itching  in  all  individuals. 

It  may  therefore  be  stated,  with  llebra,  that  under  these  con- 
ditions, pruritus  is  physiological. 

Scratching  in  such  cases  may  be  really  useful,  being  a  defensive 
movement  which  may  be  reflex  and  sometimes  unconscious,  whose 
aim  is  the  removal  of  the  injurious  agent. 

Uncleanliness  or,  on  the  contrary,  the  excessive  use  of  soap,  etc., 
may  also  be  the  cause  of  persistent  itching. 

The  severity  and  duration  of  artificial  pruritus  are  governed  by  a 
personal  coefficient;  it  varies  with  the  age  of  the  patient,  his  tem- 
perament, his  physical  and  reactionary  state,  his  hygienic  habits  and 
the  possible  existence  of  a  faulty  diathesis.  It  can  be  modified, 
moreover,  by  suggestion  or  autosuggestion;  many  people  feel  like 
scratching  as  soon  as  the  conversation  turns  on  lice  or  bugs.  It 
may  assume  the  proportions  of  an  obsession,  a  neurosis  or  mania — 
a  condition  which  is  designated  under  the  name  of  parasitophobia, 
acarophobia,  or  dermatophobia.  Inversely,  it  is  at  least  modified  by 
habituation,  intercurrent  fibrile  diseases,  etc. 

Secondary  Pruritus.— Many  dermatoses  of  external  or  internal 
origin  include  pruritus  among  their  usual  or  possible  symptoms. 

When  the  pruritus  accompanies  or  follows  the  eruption,  the  inter- 
pretation of  the  fact  is  relatively  simple. 

It  may,  however,  precede  it.  In  such  cases,  the  question  arises 
if  the  pre-eruptive  pruritus  is  the  effect  of  not  yet  perceptible  his- 
tological lesions,  or  if  it  is  a  concomitant  or  preliminary  effect  of  the 
cause  which  is  about  to  give  rise  to  the  eruption,  or  finally  if  it  is  not 
itself  the  cause  of  this  eruption  by  the  scratching  which  it  causes; 
in  other  words,  if  it  is  not  a  primary  pruritus. 

The  solution  of  this  question  in  the  different  cases  which  may 
present  themselves,  constitutes  one  of  the  principal  difficulties  of  the 
pruritus  and  prurigo  problem. 

There  would  be  no  advantage  in  dwelling  at  length  on  pruritus 
in  the  dermatoses;  this  symptom,  with  its  peculiarities,  has  been 
pointed  out   in  each  skin  affection  separately.     The  most  pruritic 


PRIMARY  PRURITUS  483 

of  these  diseases  are  scabies,  urticaria,  eczema,  certain  medicinal 
eruptions,  lichen  planus,  Duhring's  disease,  certain  erythrodermas, 
some  leukemias  and  mycosis  fungoides. 

As  the  result  of  scratching  in  the  pruritic  dermatoses  the  lesions 
of  lichenization  may  appear  and  one  may  speak  therefore  of  secondary 
prurigo. 

On  the  contrary,  many  cutaneous  affections  practically  never 
give  rise  to  itching,  notably  the  syphilides,  psoriasis,  lupus,  leprosy, 
tumors,  etc. 

PRIMARY   PRURITUS. 

This  designation  is  applied  to  pruritus  which  is  not  connected 
with  an  external  and  evident  cause.  The  skin  is  healthy,  but, 
nevertheless,  there  is  itching,  sometimes  to  an  intolerable  degree. 
Strictly  speaking,  this  pruritus  should  not  figure  among  the  derma- 
toses; but  although  the  seat  of  the  disease  is  elsewhere,  the  derma- 
tologist's advice  is  invariably  sought  because  the  symptom  resides 
in  the  skin. 

This  primary  pruritus  may  be  diffuse  and  even  generalized,  or 
it  may  be  localized;  the  fact  must  be  emphasized  from  the  start 
that  an  internal  and  general  cause  may  manifest  itself  by  a  regional 
or  partial  disturbance. 

Pathogenesis. — The  pathogenesis  of  primary  pruritus,  also  known 
as  essential  pruritus  or  pruritus  from  internal  causes,  has  long 
taxed  the  ingenuity  of  physicians.  Anticipating  the  data  of  posi- 
tive knowledge,  it  has  been  assumed  to  depend  sometimes  on 
a  systemic  disorder  through  intoxication,  auto-intoxication  or 
nutritional  disturbance:  dyscratic  pruritus;  in  other  cases,  on  a 
nervous  disturbance  or  even  on  a  neurosis:  nervous  pruritus. 
The  distinction  between  these  two  pathogenic  mechanisms  is  some- 
times not  easily  made  and  rests,  moreover,  merely  on  hypotheses. 

Auto-intoxication  actually  seems  to  be  involved  in  the  pruritus 
of  icterus,  diabetes,  uremia  and  dyspepsias,  which  have  their  coun- 
terparts in  the  toxic  pruritus  due  to  morphin,  belladonna,  caff  em- 
poisoning, botulism,  etc.  However,  in  order  to  produce  pruritus, 
the  action  of  the  poison  must  necessarily  affect  some  part  of  the 
nervous  system-,  terminal  or  central;  making  use  of  a  bold  figure 
of  speech,  it  has  even  been  said  that  it  is  the  convolutions  of  his 
brain  which  the  patient  scratches  on  the  skin.  Hence,  although 
of  toxic  origin,  this  dyscratic  pruritus  would  be  nervous  in  its 
mechanism. 

On  the  other  hand,  it  is  an  extremely  obvious  fact  that  a  pruritus 
may  result  from  a  nervous  perturbation,  the  proof  is  furnished  by 
emotional  pruritus,  irritative  pruritus,  the  pruritus  of  tabes,  that  of 
certain  classified  neuroses,  such  as  neurasthenia,  chorea,  etc. 


484         NEURODERMATOSES— PRURITUS  AND  PRURIGO 

The  statement  has  even  been  made  that  a  pruritus  not  referable 
to  an  external  cause  or  to  an  exogenic  or  endogenic  toxic  factor 
might  be  considered  as  an  autonomous  neurosis,  an  idea  which  is 
expressed  in  the  term  of  neuroderma,  introduced  by  Brocq. 

By  Jacquet,  who  made  a  specialty  of  the  study  of  the  sensory 
disturbances  of  the  skin,  pruritus  was  interpreted  merely  as  the 
exaggeration  of  the  normal  cutaneous  sensations;  in  the  physio- 
logical condition,  the  total  sensations  coming  from  the  integument 
constitute  a  harmonious  whole,  which  may  be  called  euderma; 
when  this  balance  is  disturbed,  for  example,  under  the  influence  of 
cerebral  strain,  or  the  absorption  of  certain  foods,  pruritus  makes 
its  appearance. 

Etiology. — The  causes  of  primary  pruritus  are  infinitely  variable 
and  of  different  kinds.  As  general  and  predisposing  causes  may  be 
mentioned  the  race,  the  geographical  and  social  environment  (J.  C. 
White  says  that  in  the  United  States  pruritus  is  a  national  disease; 
in  European  countries  the  Jews  pay  a  heavy  toll) ;  a  nervous  or 
arthritic  heredity,  resulting  from  a  bad  hygiene  of  overnourished, 
gouty,  diabetic,  etc.,  progenitors;  and  the  age  of  greatest  activity, 
which  is  from  twenty  to  forty  years,  in  both  sexes. 

The  following  conditions  act  as  favoring  or  determining  factors: 
Brain-fag,  which  is  Aery  common  in  large  cities;  worry;  late  hours; 
grief;  venereal  excesses;  cold  and  heat,  some  forms  being  seasonal; 
Duhring  described  a  pruritus  hiemalis  (winter  pruritus)  which  is 
often  a  prurigo;  Bazin  reported  a  pruritus  a  colore  in  persons 
employed  in  the  vicinity  of  fires; — and  hygrometric  and  barometric 
variations,  to  which  some  pruritics  are  susceptible. 

To  the  same  group  of  causes  belong  the  following:  Dietetic 
errors,  overeating,  abuse  of  meats,  condiments,  stimulating  bever- 
ages, such  as  coffee,  tea,  alcoholic  drinks,  etc.;  a  bad  condition  of 
the  teeth  and  gums,  also  habitual  constipation,  which  act  as  intoxi- 
cations; and  the  employment  of  certain  remedies  which  cause  a 
toxic  pruritus,  for  example,  belladonna,  caffein,  arsenic,  morphin, 
opium,  cocain,  etc. 

Diathetic  or  dyscratic  pruritus  is  often  referable  to  auto-intoxi- 
cations, nutritional  disturbances,  functional  disturbances  or  organic 
lesions  of  the  viscera,  the  following  being  represented  in  this  etiology : 
diabetes,  gout,  obesity,  hepatism — with  or  without  cholemia  and 
often  out  of  proportion  to  the  degree  of  icterus,  but  perhaps  related 
to  the  cholesterinemia,  major  and  minor  uremia,  pyelonephritis, 
chronic  enteritis,  chronic  appendicitis,  circulatory  disturbances, 
cancer,  tuberculosis,  the  leukemias,  etc. 

The  nervous  disturbances  accompanied  by  pruritus  are  less 
frequently  those  of  organic  origin  like  hemiplegia,  brain  tumors, 
general    paralysis    and    tabes    (Milian)    than    those    of   functional 


PRIMARY  PRURITUS  485 

character.  Nervous  pruritus  is  commonly  observed  among  social 
failures,  unhappy  inventors,  mental  defectives,  as  the  result  of  too 
much  work  or  too  much  play  and  as  the  sequel  of  an  emotional 
disturbance;  the  original  depression  is  aggravated  by  the  con- 
stantly recurring  distress  and  by  insomnia,  leading  to  neurasthenia, 
melancholia  and  sometimes  suicide.  Formerly,  cases  of  pruritus 
connected  with  pregnancy,  menstrual  disturbances,  utero-ovarian, 
prostatic  or  vesical  diseases,  were  interpreted  as  reflex  pruritus, 
but  these  are  now  referred  rather  to  auto-intoxications. 

Hematogenic  pruritus  is  observed,  although  inconstantly,  in  the 
leukemias  and  may  lead  to  the  recognition  of  the  blood  disease. 

Determining  causes  are  those  which  may  excite  a  latent  pruritus 
and  bring  on  a  crisis.  The  time  of  disrobing  at  night  is  very  com- 
monly dreaded  by  pruritic  patients,  as  it  becomes  the  occasion  of 
a  real  paroxysm;  it  is  impossible  to  say  if  the  exposure  to  cold, 
contact  with  the  air  or  decompression  are  responsible;  at  any  rate, 
many  healthy  persons  scratch  when  disrobing,  notably  the  majority 
of  women  after  having  removed  their  corsets,  belts  or  garters. 

The  attacks  may  also  be  brought  on  by  a  bath,  rapid  walking, 
cold  or  heat,  even  by  a  perfectly  harmless  meal.  Certain  persons 
are  attacked  by  pruritus  immediately  after  the  ingestion  of  some 
food  or  drink,  before  any  actual  absorption  can  have  taken  place 
as  if  under  the  effect  of  a  reflex;  as  particularly  harmful  in  this 
respect  are  mentioned  acid  fruits,  mussels  and  shellfish,  cheeses, 
spices,  alcoholic  beverages,  tea,  coffee,  etc. 

Often,  however,  the  attacks  occur  spontaneously,  even  during 
sleep,  apparently  resulting  from  a  nervous  discharge. 

A  few  general  data,  well  elucidated  by  Jacquet,  dominate  the 
etiology  of  pruritus: 

1.  Predisposing  and  determining  causes,  internal  and  external, 
are  often  associated  and  act  through  a  cumulative  effect  constitut- 
ing the  prurigenetic  summation. 

2.  A  preceding  pruritus  invites  another;  apparently  each  organic 
cell  stores  up  more  or  less  the  stimulation  which  it  has  undergone, 
through  a  kind  of  local  memory;  this  is  prurigenetic  mnemoderma. 

3.  The  accumulated  sensory  energy  may  become  stationary  or 
it  may,  on  the  contrary,  become  transported  and  transformed, 
representing  sensory  metastasis. 

Symptoms. — Pruritus,  being  an  essentially  subjective  phenome- 
non, manifests  itself  only  by  scratching.  Just  as  there  are  all 
possible  degrees  of  itching,  from  a  slight  distress,  which  is  easily 
forgotten,  to  an  imperious,  inexorable  necessity,  against  which  no 
provision  holds  out,  so  there  are  likewise  all  sorts  and  forms  of 
scratching.  An  insignificant  pruritus  yields  to  simple  rubbing  with 
the  finger-tip;  a  severe  attack  requires  forcible  scratching  with  the 


486         NEURODERMA  TOSES— PRURITUS  AND  PRURIGO 

nails  <>r  rubbing  with  a  rough  towel,  a  brush  or  some  other  instru- 
ment which  the  patient  uses  as  a  curry-comb;  sometimes  a  cold  or 
hot  application  may  accomplish  the  same  object. 

No  relation,  however,  can  be  established  between  the  severity 
of  the  pruritus  and  the  scratching,  which  is  modified  by  individual 
factors  or  conditions  inherent  to  the  disease. 

Whoever  has  witnessed  a  characteristic  pruritic  crisis  will  retain 
a  lasting  impression.  At  the  onset,  the  patient  endeavors  to  con- 
trol himself;  gradually  he  yields  to  the  need  of  scratching,  which 
incessantly  increases,  its  satisfaction  being  accompanied  by  a 
truly  voluptuous  sensation;  all  restraint  is  promptly  lost;  pale, 
anxious,  distracted  by  his  trouble,  the  patient  furiously  excoriates 
himself,  mutilating  his  skin  and  literally  torturing  himself,  as  if 
in  the  power  of  a  blind  force.  Sometimes  it  is  not  until  the  skin 
is  raw  and  streams  with  blood  that  relaxation  occurs,  satisfaction 
is  obtained  and  the  attack  is  over.  The  patient  remains  exhausted 
and  as  if  ashamed  of  himself.  Comparison  with  an  epileptic  attack 
and  that  involved  in  the  term  of  "cutaneous  masturbation"  is 
entirely  justified. 

It  is  impossible  to  say  why  scratching,  even  when  carried  to  such 
an  excess,  produces  relief;  but  all  pruritic  patients  declare  that  the 
burning  pain  of  the  excoriations  is  preferable  to  the  annoyance  of 
the  itching. 

The  attacks  usually  last  from  five  to  fifteen  minutes,  sometimes 
an  hour  or  longer;  there  is  no  rule  as  to  their  frequency  and  the 
rhythm  of  their  recurrence. 

The  pruritus  described  above  may  be  diffuse  and  even  general- 
ized; it  is  more  frequently  partial,  regional,  localized  on  a  more  or 
less  extensive  portion  of  the  integument.  But  a  diffuse  pruritus 
sometimes  tends  to  become  localized  after  a  certain  time  or.inversely, 
a  regional  pruritus  may  be  seen  later  on  to  radiate  and  become 
diffuse. 

It  is  a  noteworthy  fact  that  a  localized  pruritus,  originating  under 
the  influence  of  a  local  cause,  may  recur  in  situ  on  the  occasion  of 
an  internal  or  general  cause,  through  the  effort  of  the  mnemoderma 
referred  to  above;  in  this  way  an  anal  pruritus,  for  instance,  caused 
by  oxyuris  or  hemorrhoids,  wrill  recur  at  the  time  of  dietetic  errors 
or  overexertion. 

The  consequences  of  scratching  are  partly  immediate  and  partly 
remote.  The  traumatism  produces  in  the  first  place  congestion, 
with  local  heat  and  more  or  less  interstitial  exudation,  that  is, 
simple  or  urticarial  erythema. 

I  believe  that  by  itself  alone  it  may  also  excite  an  eczematous 
reaction,  traumatic  eczema  (Chapter  IV). 


PRIMARY  PRURITUS  1X7 

More  forcible  scratching  causes  linear  excoriations,  usually 
directed  in  the  course  of  the  nails,  which  suggests  their  origin  in 
spite  of  denial  on  the  patient's  part.  Often  the  excoriations  are 
punctiform  and  occupy  follicular  prominences,  because  from  the 
beginning  of  the  irritation  the  congested  follicles  have  been  raised  by 
a  spasm  of  their  erector  muscles  and  have  projected  above  the  gen- 
eral level.  These  excoriated  follicular  papules,  covered  with  a  bloody 
or  serous  crust,  must  not  be  confused  with  the  papules  of  prurigo. 

The  remote  effects  of  scratching  are  in  part  of  a  special  kind, 
consisting  of  papulation  or  lichenization  and  suffice  to  place  a  given 
case  of  pruritus  in  the  group  of  the  prurigos. 

Others  are  of  an  ordinary  kind,  namely  secondary  infection  by 
pyococci,  through  the  avenue  of  the  traumatism  giving  rise  to  the 
most  varied  pyodermatitides.  Even  in  the  absence  of  suppura- 
tion, chronic  scratching  causes  hypertrophy  of  the  concatenated 
glands.  Pigmentation,  more  or  less  diffuse,  is  likewise  common. 
The  worn-off  nails  which  become  polished  and  shining,  have  been 
mentioned  elsewhere  (Fig.  138). 

It  will  be  seen,  with  Jadassohn,  that  from  the  standpoint  of  the 
effects  of  scratching,  the  pruritic  diseases  may  be  divided  into 
two  classes:  in  the  first,  the  patient's  nails  tear  off  everything  that 
protrudes  and  even  dig  into  the  epidermis  to  tear  off  shreds  of 
tissue;  this  biopsic  pruritus,  as  it  was  called  by  Besnier,  is  observed 
in  scabies,  pediculosis,  sometimes  in  diabetes,  Duhring's  disease 
and  the  prurigo  of  Hebra.  Pyodermatitides  are  commonly  present 
in  these  cases. 

The  second  form  of  pruritus,  although  sufficient  to  cause  insom- 
nia, is  relieved  by  friction,  pressure,  etc.,  and  is  unaccompanied  by 
any  traces  of  scratching.  Senile  pruritus,  the  pruritus  of  lichen 
planus,  of  some  types  of  icterus,  of  urticaria  and  of  phthiriasis,  belong 
to  this  group.     The  reasons  for  this  difference  are  unknown. 

Clinical  Forms. — It  is  not  easy  to  formulate  a  picture  of  the 
forms  of  pruritus  according  to  their  origin.  The  following  general 
remarks  may  be  made  on  this  subject. 

Dyscratic  pruritus,  that  of  diabetes  and  icterus  in  particular, 
is  often  generalized,  is  observed  in  relatively  aged  individuals,  is 
especially  nocturnal  and  gives  rise  to  deep  multiple  excoriations. 

Nervous  pruritus,  or  neuroderma  of  Brocq,  attacks  youthful  or 
adult  persons,  is  often  regional  or  partial,  occupying  for  example 
the  large  articular  folds,  the  external  aspect  of  the  limbs,  etc.  It 
has  a  marked  tendency  to  lichenization  and  consequently  to  prurigo 
vulgaris. 

Hematogenous  pruritus  is  accompanied  by  a  change  in  the  blood 
(leukemias  and  anemias),  easily  recognized  when  kept  in  mind  and 
looked  for. 


488         NEURODERMATOSES— PRURITUS  AND  PRURIGO 

Senile  pruritus,  described'hyVWillan,  formerly  covered  almost  all 
the  forms  of  pruritus  of  aged  individuals.  At  the  present  time 
this  name  is  restricted  to  a  chronic,  almost  invariably  generalized, 
remittent  pruritus,  in  which  the  skin  is  flabby,  dry,  rough  or  smooth, 
more  or  less  senile,  but  very  resistant  to  scratching.  As  a  matter 
of  fact,  even  in  severe  senile  pruritus,  neither  excoriations,  nor 
urticaria,  nor  papules,  nor  lichenization  are  noted.  This  form  is 
very  rebellious  to  treatment. 

Localized  pruritus  is  provoked  by  and  depends  upon  either  a 
local  or  a  general  cause.  A  general  prurigenetic  cause  often 
localizes  its  effects  in  a  region  which  has  first  been  irritated  in  some 
way  or  takes  advantage  of  an  ordinary  local  lesion,  such  as  varicose 
veins  or  metritis,  to  lodge  in  its  vicinity.  The  interest  in  this 
localized  pruritus  is  derived  from  the  existence  of  these  predisposing 
conditions  which  it  reveals  and  which  can  often  be  remedied.  Not 
infrequently  it  becomes  eczematized,  thereby  leading  to  confusion 
with  the  pruriginous  eczemas,  or  it  may  also  develop  into  prurigo. 

Anal  pruritus,  which  is  perhaps  the  most  common  variety,  at  any 
rate  one  of  the  most  obstinate  and  demoralizing  forms,  is  often 
connected  with  the  presence  of  oxyuris,  lumbricoides,  hemorrhoids, 
fissures,  or  with  habitual  constipation. 

Perigenital  pruritus,  sometimes  associated  with  the  preceding,  is 
frequently  related  to  diabetes,  cystitis,  diseases  of  the  prostate, 
gonorrhea,  or  strictures  of  the  urethra.  Vulvar  pruritus  is  suggestive 
of  leukorrhea,  diseases  of  the  vagina,  uterus  and  adnexa;  it  is  not 
uncommon  at  the  menopause  or  after  spaying.  It  may  create  the 
suspicion  of  or  excite  masturbation. 

Nasal  and  peribuccal  pruritus  is  often  caused  by'  coryza,  rhino- 
pharyngeal  lesions,  dental  caries,  neglected  inflamed  gums,  or 
badly  fitting  artificial  dentures.  Buccal  pruritus  may  occupy  the 
lips,  the  cheeks,  as  well  as  the  tongue;  it  is  often  associated  with 
the  neuralgia  known  as  glossodynia. 

Pruritus  of  the  hairy  regions  is  usually  symptomatic  of  parasites 
or  of  kerosis,  pityriasis,  etc. 

Palmar  and  plantar  pruritus,  described  by  Alibert  and  Hebra,  is 
always  symmetrical.  It  is  rare  and  is  encountered  in  unbalanced 
and  toxic  persons.  It  often  assumes  the  form  of  burning  sensations 
with  nocturnal  paroxysms.  There  is  no  trace  of  scratching.  It 
must  be  distinguished  from  dysidrosis  and  from  eczema. 

PRURIGO. 

I  employ  the  term  prurigo  to  indicate  that  group  of  pruritic 
affections  in  which  the  itching,  which  is  the  primary  phenomenon, 
becomes  associated  under  the  influence  of  scratching  with  special 


PRURIGO  489 

cutaneous  reactions,  in  the  form  of  lichenization  and  prurigo 
papules. 

This  definition,  which  is  not  given  by  all  authors,  is  justified  by 
the  historical  development  of  this  question  and  meets  with  the 
nosographical  requirements. 

Willan  grouped  prurigo  under  his  heading  of  papules,  which 
comprised:  (1)  strophulus;  (2)  lichen;  (3)  prurigo.  Credit  is  due 
to  Cazenave  and  Canuet  for  recognizing  that  in  prurigo  the  itching 
is  primary  and  the  papule  secondary.  The  elder  Hebra  again 
reverted  to  the  idea  that  prurigo  is  characterized  by  a  primary 
papule,  a  view  which  has  since  been  refuted.  Modern  investiga- 
tions, especially  those  of  Brocq  and  Jacquet,  have  established  the 
almost  universally  accepted  fact  that  the  papules  of  prurigo  and 
lichenization  are  secondary  to  the  pruritus  and  due  to  the 
scratching. 

Accepting  the  above  definition  (prurigo  =  primary  pruritus  + 
special  papules  or  lichenization),  the  diagnosis  of  the  prurigos 
becomes  easy  and  the  relations  which  they  bear  to  associated 
dermatoses  are  readily  understood. 

In  'pruritus,  there  may  be  traumatic  lesions  from  scratching, 
pyodermatitides  and  artificial  eczema,  but  there  are  neither  lichen- 
ization nor  prurigo  papules. 

Urticaria  is  a  syndrome  in  which  pruritus  and  scratching  are 
accompanied  by  the  rapid  appearance  of  very  ephemeral  urticarial 
papules.  In  some  forms  of  prurigo  the  skin  is  seen  to  react  in 
the  form  of  urticaria,  especially  at  the  onset;  the  etiology  of  the 
chronic  urticarias  coincides  in  its  general  outlines  with  that  of 
pruritus  and  the  prurigos;  we  must  therefore  admit  the  existence  of 
a  certain  kinship  between  these  two  groups  of  dermatoses. 

Eczema,  irrespective  of  its  cause,  may  assume  a  lichenoid  appear- 
ance and  become  extremely  pruriginous.  On  the  other  hand,  the 
prurigos  frequently  become  eczematized.  It  is  readily  understood 
that  the  differential  diagnosis  between  these  two  groups  of  cases, 
lichenoid  eczema  and  eczematized  prurigo,  resting  as  it  does  merely 
on  the  priority  of  the  pruritus  or  the  eruption  and  on  the  more  or 
less  diffused  lichenoid  state,  often  presents  almost  insurmountable 
difficulties. 

Several  other  pruritic  dermatoses  may  ultimately  become 
associated  with  lichenization.  The  existence  of  secondary  prurigos 
may  accordingly  be  admitted,  as  well  as  the  more  frequent  occur- 
rence of  secondary  pruritus. 

Symptoms. — It  is  not  necessary  to  repeat  what  has  been  said 
about  primary  pruritus,  its  etiology,  its  pathogenesis  and  its  clinical 
manifestations. 

The  papules  of  strophulus  and  of  prurigo  have  been  already 


I'.HI 


VEURODERMA  TOSES—PRURITt  's  AXD  PRtJRlCfd 


described  (p.   1  10).     All  that  remains  to  be  discussed  in  this  con- 
nection is  lichenization. 

Lichenization  (Besnier),  which  Mas  first  fully  described  by  Brocq 
under  the  name  of  lichenification,  is  a  chronic  more  or  less  persist- 
ent change  in  the  appearance  and  the  structure  of  the  integument 
(Fig.  147).  The  lichenized  skin  is  thickened  as  a  whole;  it  may  be 
described  as  striated,  wrinkled,  leathery,  without  either  of  these 
words  conveying  an  exact  idea  of  the  condition.  Its  peculiar 
appearance  is  really  characterized  as  an  exaggeration  of  the  fine 


Fig.   147. — Lichenization  of  the  skin  of  the  internal  aspect  of  the  thigh,  in  a  case  of 
prurigo  vulgaris,  in  a  woman  aged  forty  years. 


striae  which  normally  traverse  it,  which  results  in  a  criss-cross  net- 
work with  fairly  regular  meshes,  more  or  less  wide  or  narrow  accord- 
ing to  the  region  affected,  resembling  the  cross-hatching  of  an 
engraving.  The  meshes  are  square,  lozenge-shaped,  or  polygonal; 
they  have  a  flat  surface  and  usually  present  the  appearance  of 
smooth  shining  facets,  like  mosaic  work.  Sometimes  they  are 
covered  with  fine  scales. 

The  lichenized  skin  is  less  supple  than  the  normal  skin;  its  color 
is  normal,  or  more  often  of  a  grayish  or  brownish  hue;  sometimes 
it  is  hypochromic. 


PRURIGO  491 

Its  histological  structure  is  less  altered  than  one  might  be  led 
to  believe;  the  lesions  consist  of  acanthosis,  with  elongation  of  the 
papillae  and  moderate  infiltration  of  the  papillary  body. 

The  lichenization  occupies  surfaces  of  very  variable  extent,  in 
patches  or  areas,  with  diffuse  borders,  where  there  is  a  gradual 
transition  to  a  normal  appearance.  [It  is  characteristic  of  the 
border  that  it  is  not  limited  by  curved  lines  but  is  made  up  rather 
of  short  rectilinear  elements.]  On  these  borders,  or  on  a  surface  in 
course  of  lichenization,  only  a  few  shining  polygonal  facets  are 
noted,  appearing  very  slightly  papular;  but  not  indurated. 

Lichenization  must  be  distinguished  from:  the  patches  of 
lichen  planus  (Fig.  33)  which  are  made  up  by  the  confluence  of 
genuine  planus  papules  and  surrounded  by  typical  papules;  and 
from  the  lichenoid  condition  sometimes  assumed  by  eczemas, 
eczematides  and  psoriasis;  this  is  characterized  by  thickening  and 
accentuation  of  the  folds  and  furrows,  but  it  is  red,  without  shining 
facets  and  distinctly  circumscribed  at  its  borders.  The  striated 
and  roughened  condition  sometimes  presented  by  the  skin  of  the 
genitocrural  regions  in  gonorrheic  women,  a  condition  described 
by  Brocq  and  L.  Bernard,  very  closely  resembles  lichenization, 
although  the  surface  according  to  these  writers,  is  more  villous  and 
velvety. 

Lichenization  may  be  primary  and  pure,  that  is,  it  develops  on 
a  previously  healthy  skin  under  the  influence  of  rubbing  and  scratch- 
ing caused  by  pruritus;  under  this  form  it  is  the  principal  and 
most  characteristic  lesion  of  diffuse  prurigo  vulgaris;  or  it  may  be 
associated  with  the  above-mentioned  dermatoses,  lichen,  eczema, 
eczematides,  etc. 

Since  lichenization  is  a  peculiar  reaction  of  the  skin  under  the 
influence  of  repeated  traumatisms,  the  question  may  arise  why  does 
it  not  develop  on  all  surfaces  exposed  to  friction,  or  in  all  pruritic 
persons  who  scratch  themselves.  I  shall  restrict  myself  to  giving 
the  explanations  offered  by  Brocq,  who  says  that  some  cutaneous 
affections  modify  the  vitality  or  the  nutrition  of  the  tissues  in  such 
a  way  that  lichenification  occurs  with  the  greatest  facility,  whereas 
in  other  pruritic  affections  the  resistance  of  the  tissues  seems  to 
be  normal  or  even  increased;  moreover,  some  individuals  are 
especially  predisposed  to  react  in  one  or  another  way.  [It  must  be 
admitted  that  this  explanation  explains  nothing;  it  simply  restates 
the  facts.]  The  same  theories  are  applicable  to  the  pathogenesis 
of  prurigo  papules. 

As  to  the  papules  of  strophulus,  the  question  of  their  being  of 
primary  origin  or  secondary  to  the  scratching,  remains  doubtful; 
it  seems  to  me  that  they  are  often  encountered  at  points  of  the  skin 
which  the  patient  can  in  no  way  injure  or  scratch. 


402         NEURODERMATOSES— PRURITUS  AND  PRURIGO 

Clinical  Forms. — The  prurigos  constitute  a  continuous  scries  of 
morbid  types,  extending  from  eases  related  to  urticaria  to  formi- 
dable dermatoses  such  as  prurigo  ferox.  It  would  be  desirable  to 
classify  them  into  varieties  and  this  has  been  attempted  by  many 
dermatologists,  who  always  emphasized  those  types  which  they 
had  been  best  enabled  to  study.  Hence  the  subdivisions  of  some 
do  not  agree  with  those  of  others  and  it  is  very  difficult  to  find  one's 
way.  Without  aiming  at  completeness,  I  shall  limit  myself  to 
describing  three  principal  forms: 

Acute  Prurigo  Simplex  or  Strophulus. — The  affection  named 
strophulus  by  Willan  and  Bateman  and  acute  lichen  simplex  by 
Vidal,  was  given  by  Brocq  the  excellent  name  of  prurigo  simplex 
acutus,  a  name  which  has  been  received  with  general  favor;  abroad 
the  terms  of  urticaria  papulosa  and  lichen  urticatus  are  often 
employed. 

The  condition  is  an  acute  benign  prurigo,  characterized  by  a 
special  and  exclusive  lesion,  the  strophulus  papule,  generally  origi- 
nating upon  an  urticarial  base;  an  eruption  advancing  in  rapid, 
successive  or  overlapping  crops,  scattered  over  the  entire  body;  the 
usual  absence  of  lichenization  and  eczematization;  a  limited  dura- 
tion, of  a  few  weeks  to  a  few  months,  but  with  possible  relapses; 
and  on  the  whole  a  favorable  prognosis. 

Etiology. — Strophulus  is  of  extreme  frequency  in  early  childhood ; 
later  in  life  it  is  observed  much  more  rarely,  but  is  not  unknown, 
however,  in  the  period  from  fifteen  to  twenty-five  years. 

A  predisposition  in  certain  families  is  obvious.  It  is  encountered 
in  apparently  perfectly  healthy  children.  However,  two  deter- 
mining etiological  factors  can  often  be  recognized:  (1)  Overfeed- 
ing or  underfeeding,  digestive  disturbances,  gastro-intestinal  fermen- 
tations, constipation,  etc.;  (2)  the  influence  of  teething,  which  is 
accompanied  by  nervous  disturbances,  excitement,  insomnia  and 
often  also  by  digestive  disturbances.  1  have  elsewhere  pointed  out 
that  the  second  period  of  life  where  strophulus  is  frequently  met 
with  corresponds  to  that  of  the  eruption  of  the  wisdom  teeth. 

Symptoms. — Suddenly,  in  the  midst  of  health,  or  sometimes 
after  a  slightly  febrile  general  malaise,  lasting  one  or  several  days, 
the  eruption  makes  its  appearance.  It  consists  of  urticarial 
spots  surrounding  and  at  first  concealing  the  papule  which  has 
been  previously  described.  Sometimes,  a  few  urticarial  elevations 
without  papules  are  likewise  noted  and  are  easily  brought  on  by 
scratching. 

This  eruption  is  located  anywhere,  at  the  onset  preferably  on  the 
upper  extremities  and  on  the  trunk;  later,  on  the  lower  limbs,  on 
the  neck  and  on  the  face;  the  palms  and  the  soles  are  only  rarely 
involved. 


PRURIGO 


493 


An  eruption  proceeds  in  crops  of  four  or  five,  to  about  twenty 
lesions;  it  recurs  every  day,  or  every  second  or  third  day.  The 
urticarial  spot  lasts  only  a  few  hours  and  then  it  fades,  but  the 
papule  lasts  from  four  to  ten  days.  It  is  therefore  not  uncommon 
to  see  children  covered  with  lesions  of  different  ages  (Fig.  148), 
some  incipient,  others  at  their  acme  or  undergoing  retrogression; 
and  sometimes  with  not  very  persistent  macules. 

Sometimes  the  lesions  are  small  vesicles  originating  on  an  urticar- 
ial base;  on  the  palms  or  the  soles  these  vesicles  may  attain  the  size 
of  a  lentil. 


Fig.  148. — Profuse  eruption  of  strophulus,  or  prurigo  simplex  acutus,  in  a  boy 
aged  six  years. 


The  course  extends  over  a  very  variable  period,  from  three 
weeks  to  three  months;  recurrences  are  common  in  little  children; 
toward  the  age  of  three  years  the  disease  usually  subsides.  If  it 
persists,  there  is  danger  of  the  development  of  Hebra's  prurigo. 

Pruritus  is  variable  and  remittent,  but  often  very  severe.  Some 
individuals  scratch  furiously  and  excoriate  some  of  their  papules; 
it  seems,  although  this  cannot  be  positively  stated,  as  if  the  scratch- 
ing gave  rise  to  new  papules.  Eczematization  and  pyodermatitis 
are  rare. 

The  diagnosis  rests  upon  the  demonstration  of  the  typical  papule, 
capped  by  a  tiny  lenticular  yellow  crust.  In  infants  strophulus  is 
often  confused  with  urticaria,  the  stings  of  insects,  sudoral  and 
medicinal  eruptions;  in  the  young,  with  acne,  papular  erythema, 


494         NEURODERMATOSES— PRURITUS  AXD  PRURIGO 

acute  disseminated  eczema.  Cases  where  the  eruption  is  plainly 
vesicular  may  suggest  varicella;  it  should  be  kept  in  mind  that 
the  lesions  of  the  latter  are  less  pruriginous  [are  most  abundant  on 
the  back  and  frequent  on  the  scalp]  and  do  not  spare  the  buccal 
mucosa. 

Prurigo  simplex  is  evidently  insufficiently  known,  for  it  is  con- 
stantly being  re-described  by  physicians  under  some  arbitrary 
denomination. 

The  treatment  consists  in  correcting  and  regulating  the  diet;  it  is 
often  advisable  to  diminish  the  quantity  of  milk  and  give  a  purga- 
tive or  laxatives,  among  which  calomel  is  most  to  be  recommended 
for  children. 

Locally,  acidulated,  carbolized  or  anodyne  washes  are  preferable 
to  baths,  which  are  often  not  well  borne.  Zinc  pastes  with  tumenol 
and  tar  and  occlusion  by  well-applied  bandages  when  possible,  are 
effective  against  the  itching. 

Hebra's  Prurigo. — From  the  chaos  of  the  pruriginous  diseases, 
Ilebra  picked  out  a  morbid  type  which  is  designated  under  his  name; 
a  mild  form  {prurigo  mitis)  is  known,  as  well  as  a  grave  and  chronic 
form,  characterized  by  a  special  course  and  by  very  polymorphous 
and  severe  lesions.  It  corresponds  to  the  lichen  agrius  of  the 
ancients  and  more  or  less  accurately  to  the  lichen  polymorphe 
ferox  of  Yidal. 

As  a  rule  the  disease  begins  in  the  course  of  the  first  year  of 
life,  in  the  form  of  urticaria  or  strophulus,  with  severe,  recurrent, 
very  pruriginous  attacks,  but  in  many  cases  the  pruritus  comes  on 
directly,  without  premonitory  eruptions. 

At  the  end  of  a  year  or  two,  it  reaches  its  fully  developed  stage 
and  the  clinical  picture  is  characteristic:  The  child  is  tormented 
by  incessant  itching,  or  the  pruritus  may  vary  according  to  the 
season  of  the  year.  The  skin  is  covered  with  linear  or  papulo- 
follicular  excoriations,  crusts,  cicatrices,  diffuse  or  regional  eczema- 
tizations,  pyodermatitides;  it  is  thickened,  coarse,  pigmented  and 
lichenized  over  large  surfaces.  The  external  aspects  of  the  extremi- 
ties are  chiefly  affected,  less  often  the  trunk  and  sometimes  the 
face;  the  large  articular  folds  almost  invariably  escape.  From 
time  to  time,  more  or  less  large  prurigo  papules  are  encountered, 
intermingled  with  the  lichenization. 

In  the  least  scratched  regions,  the  skin  has  an  earthy  color  and 
often  resembles  goose-flesh;  the  prominence  of  the  follicles  is  attrib- 
uted to  contraction  of  the  erector  muscles.  The  hairs,  although 
abundant  at  first,  soon  become  worn  off  and  disappear. 

The  lymphatic  glands  of  the  groins  and  axillae  are  always  enlarged, 
and  their  enlargement  is  often  very  evident.  Kosinophiles  are 
usually  present  in  large  numbers  in  the  blood  and  in  the  skin  itself. 


PRURIGO  495 

The  little  patients  are  sickly,  irritable,  timid,  their  persistent 
sufferings  and  habitual  insomnia  accounting  for  their  gloomy 
disposition.  When  they  grow  up,  their  infirmity  condemns  them 
to  a  solitary  existence;  they  can  share  neither  in  amusements  nor 
in  attendance  at  school. 

The  course  of  Hebra's  prurigo  is  remittent;  periods  of  relative 
calm  are  followed  by  aggravated  attacks  lasting  several  months. 
It  is  usually  not  until  puberty  or  even  about  the  age  of  twenty  to 
twenty-five  years  that  the  disease  subsides  and  becomes  attenuated ; 
from  this  time  on,  without  knowing  the  patient's  history,  one  might 
mistake  it  for  a  chronic  eczema  or  a  prurigo  vulgaris.  The  patho- 
logical manifestations  vanish  as  a  rule  in  mature  life  or  old  age, 
if  the  patient  live  long  enough. 

In  the  etiology,  the  hereditary  conditions  mentioned  above  rank 
first  in  order,  perhaps  also  to  some  extent  errors  in  feeding  in  early 
childhood.  Like  other  observers,  I  have  several  times  noted  the 
coincidence  of  Hebra's  prurigo  with  asthma.  [The  possibility  of 
sensitization  to  a  particular  article  or  kind  of  alimentary  substance 
(e.  g.,  milk,  eggs)  must  be  considered  in  the  etiology.] 

Several  varieties  of  this  prurigo  may  be  described : 

In  the  Hebra-  Kaposi  type,  the  cutaneous  lesions  increase  in 
severity  from  the  head  to  the  legs. 

In  what  has  been  called  the  French  type,  they  predominate  on 
the  face  and  the  upper  extremities,  being  on  the  contrary  less  well 
marked  on  the  legs  and  on  the  trunk. 

Prurigo  ferox  (polymorphous  lichen  ferox  of  Yidal)  is  a  rare 
type,  characterized  by  prurigo  papules  scattered  or  grouped  on  the 
extremities  (Fig.  149),  the  body  and  even  the  face;  they  are  of 
considerable  size,  approaching  the  size  of  a  cherry-pit  or  half  a 
hazel-nut,  often  excoriated  or  vesicular  at  their  apex.  On  the  other 
hand,  lichenization,  while  constant,  is  less  pronounced.  The  itching 
is  intense  and  the  disease  is  extremely  obstinate  and  of  indefinite 
duration. 

[Prurigo  nodularis  (Hyde)  is  closely  related  to  the  above.  All 
the  cases  described  in  America  have  developed  in  middle-aged 
women.  The  lesion,  five  to  twenty-five  in  number,  located  almost 
exclusively  on  the  extremities,  are  pea  to  hazel-nut  in  size,  discrete, 
often  capped  by  small  vesicles,  intensely  pruritic  and  rebellious  to 
treatment.     The  surrounding  skin  is  normal  in  appearance.] 

Cases  of  Hebra's  prurigo  of  late  onset  may  possibly  occur;  some 
are  of  doubtful  nature  and  liable  to  confusion  with  severe  cases  of 
prurigo  vulgaris;  others  are  not  infrequently  referable  to  the  leu- 
kemias,  especially  to  pseudo-leukemia  with  polynucleosis  (prurigo 
lymphadenique  of  Dubreuilh). 


196 


NEURODERMATOSES     PRURITUS  AND   PRURIGO 


Prurigo  Vulgaris,  ruder  this  name  1  designate  the  common 
form  of  prurigo,  namely  the  group  of  cases  which  belong  neither  to 
simple  pruritus  nor  to  acute  prurigo  simplex  nor  to  I  [ebra's  prurigo. 

A  distinction  is  made  l>et\\ een :  I  A  diffuse  or  generalized  form; 
it  corresponds  in  a  considerable  number  of  cases  to  the  diathetic 
prurigos  of  Besnier,  to  the  diffuse  neurodermatitis  of  Brocq,  which 
he  lias  more  recently  designated  a-  "diffuse  pruritus  with  licheni- 
fication."  2  A  circumscribed  form,  corresponding  to  the  circum- 
scribed lichen-  of  the  older  author-,  to  the  chronic  lichen  -implex  of 
Vidal,  to  the  papular  eczemas  of  Hebra  and  his  school,  to  the 
dermatitis  lichenoides  pruriens  of  Xeisser,  to  the  circumscribed 
neurodermatitis  or  circumscribed  pruritus  with  lichenification  of 
Brocq. 


I  [g.  149       Prurigo  ferox  with  large  papules    polymorphous  lichen  ferox  of  Vidal.) 


Prurigo  vulgaris  is  characterized  by  primary  pruritus;  poly- 
morphous cutaneous  lesions  among  which  lichenization  and  eczema- 
tization  predominate;  and  by  a  generally  subacute  remittent  course. 

1.  Prurigo  Vulgaris  Diffusa.  Its  etiology  is  that  of  the  primary 
prurigos  in  general,  hereditary  factor-,  neurasthenia,  metabolic  and 
nervous  disturbances,  abuse  of  coffee  or  alcohol,  emotional  causes, 
all  of  these  play  an  obvious  role,  as  well  as  the  diathetic  nutritional 
disturbances  which  are  classified  as  "arthritism." 

It  may  begin  in  childhood,  but  especially  between  twenty  and 
thirty  years;  it  is  less  common  after  fifty. 

The  affection  appear-  abruptly,  often  after  an  emotional  shock, 
persisting  for  a  few  week-;  then  follow  periods  of  subsidence  and 
intermittent   recurrences,  sometimes  of  seasonal  type. 


PRURIGO  497 

During  the  attacks  the  itching  is  continuous,  with  evening  and 
irregularly  periodical  crises;  the  scratching  may  at  first  give  rise 
to  urticaria  or  erythema;  but  more  or  less  rapidly,  in  different 
individuals,  sometimes  in  a  few  days,  it  leads  to  the  production  of 
indistinctly  outlined  surface  lichenizations,  symmetrically  occupy- 
ing the  four  extremities,  the  thorax  and  the  flanks  and  sometimes 
the  face,  which  becomes  dull  and  grayish,  with  worn-off  eyebrows. 
The  combination  of  this  diffuse  lichenization  with  medium-sized 
and  indistinct  papules,  with  pigmentation,  with  traumatic  eczema, 
excoriations  and  pyodermatitis,  constitutes  a  picture  characteristic 
because  of  its  diversity  (Fig.  150). 

The  disease  is  of  indefinite  durations  covering  months  or  years; 
it  may  heal  and  is  often  replaced  by  asthma,  hay  fever,  bronchitis, 
enteritis,  etc. 


Fig.  150.— Diffuse  prurigo  vulgaris;  right  forearm  of  a  young  woman,  aged  twenty- 
three  years,  whose  four  extremities  presented  similar  lesions;  these  lesions  consist  of 
diffuse  lichenization,  with  pigmentation  and  numerous  excoriated  papules  (diffuse 
neurodermatitis  consisting  of  pure  lichenization,  Brocq). 

There  are  numerous  varieties:  Cases  occur  in  which  the  prurigo 
follows  upon  a  long  period  of  simple  pruritus;  or  an  eczema  may 
occupy  the  foreground,  more  or  less  concealing  the  other  signs,  so 
that  many  of  these  patients  pass  under  the  label  of  chronic  eczema ; 
or  the  small  and  flat  papules  may  lead  to  a  confusion  of  prurigo 
with  lichen  planus;  and  finally,  there  are  intermediate  cases,  with 
but  few  foci  between  the  diffuse  and  the  circumscribed  form. 

Under  the  name  of  prurigo  hiemalis,  a  variety  of  this  prurigo 
described  by  Duhring  is  designated,  more  common  in  North 
America,  especially  in  men,  characterized  by  its  evident  relation 
to  the  cold  season.  The  pruritus  appears  every  fall,  is  more  severe 
in  cold  weather  and  ceases  in  the  spring.  The  first  attacks  fre- 
quently date  back  to  childhood.  The  crises  are  vesperal  and 
nocturnal,  or  may  occur  in  the  daytime  under  the  action  of  heat, 
32 


498         NEURODERMATOSES— PRURITUS  AND  PRURIGO 

The  most  common  site  of  the  itching  is  on  the  legs,  the  thighs  and 
sometimes  the  upper  limbs.  The  condition  is  a  simple  pruritus 
in  some  persons,  but  in  the  majority  of  cases  becomes  a  prurigo. 

J.  Hutchinson  has  described  a  summer  prurigo  in  every  way 
comparable  to  the  preceding. 

2.  Prurigo  Circumscripta  or  Lichen  Simplex  Chronicus  of  Vidal. — 
The  etiology  is  the  same  as  in  the  diffuse  form;  sometimes  there 
exists  a  localizing  cause,  traumatism,  internal  lesion  of  the  vicinity, 
etc.     Circumscribed  prurigo  is  more  common  in  women. 

Its  seats  of  election  are  the  posterior  portion  of  the  neck,  the 
upper  part  of  the  thighs,  the  neighborhood  of  the  genital  organs 
and  the  intergluteal  fold,  the  external  surface  of  the  legs,  the  pop- 
liteal and  axillary  spaces,  the  elbows  and  the  posterior  aspect  of 
the  forearms;  but  it  may  occupy  any  area,  including  the  palmar 
and  plantar  regions.  The  focus  is  single,  or  there  may  be  two, 
three  or  more  foci. 

At  the  onset,  there  is  only  intermittent  itching,  excited  by 
occasional  determining  causes;  next,  it  assumes  the  character  of 
distinct,  especially  vesperal  crises,  lasting  a  few  minutes,  with 
furious  scratching,  followed  by  a  voluptuous  sensation  of  relaxation. 

More  or  less  rapidly,  the  lesions  of  prurigo  develop  and  in  these 
cases  present  a  typical  appearance,  in  the  form  of  a  patch  of  chronic 
lichen  simplex  of  French  writers,  the  lichen  of  Vidal  of  foreign 
authors.  It  is  generally  oval,  averaging  the  size  of  the  hand;  three 
zones  can  be  distinguished  in  it: 

The  external  zone,  2  or  3  cm.  wide,  but  imperfectly  outlined,  is 
brownish,  quadrillated,  barely  thickened.  In  the  middle  zone 
appear  lenticular  and  hemispherical  prurigo  papules,  with  an 
excoriated  or  shining  surface  grouped  near  the  central  zone.  The 
latter  is  an  infiltrated,  hyperchromic  or  depigmented  patch,  lichen- 
ized  to  the  highest  degree,  with  a  scaly  or  macerated  epidermis 
according  to  the  region  and  more  or  less  distinctly  outlined 
borders. 

Frequently  the  patches  are  not  complete;  the  zones  which  repre- 
sent the  successive  stages  of  the  change  may  be  missing  on  one  side, 
or  altogether;  the  central  disk  may  be  replaced  by  more  or  less 
closely  agminated  papules. 

The  duration  of  a  circumscribed  prurigo  is  from  several  months 
to  one  or  two  years,  sometimes  still  longer.  Recurrences  are 
common.  Sometimes,  one  or  several  new  patches  appear  when  the 
old  ones  have  ceased  to  itch,  become  flattened  and  smoothed  out; 
Inn  the  normal  color  is  not  restored  until  long  afterward. 

The  differentia]  diagnosis  must  be  made  from  lichen  planus, 
lichen  obtusus,  the  eczematides,  the  tubercular  syphilides;  it  is 
usually  easy,  especially  with  the  help  of  the  anamnesis.     In  addi- 


PRURIGO  499 

tion  to  the  rather  common  nerve  or  less  marked  pigmentary  dis- 
turbances, or  leukomelanoderma,  cases  of  circumscribed  prurigo 
occur  in  association  with  true  vitiligo. 

Treatment  of  Pruritus  and  Prurigo. — Needless  to  say,  before 
beginning  the  treatment  of  a  pruritus  or  prurigo,  the  diagnosis  of 
its  form  and  probable  cause  must  have  been  specified  as  closely  as 
possible. 

In  the  first  place  artificial  pruritus,  of  parasitic  origin  or  due  to 
external  causes,  must  be  eliminated;  these  require  a  parasiticide 
medication  or  special  hygienic  precautions;  next,  secondary  pruritus, 
in  which  not  only  the  symptom  but  the  primary  disease  and  its 
complications  require  treatment. 

In  dealing  with  a  primary  pruritus  or  prurigo,  its  cause  must  be 
looked  for  among  intoxications,  hygienic  errors,  organic  or  func- 
tional anomalies;  the  urine  and  blood  must  be  examined,  etc.;  it 
goes  without  saying  that  the  treatment  must  take  into  considera- 
tion all  the  predisposing  or  determining  factors  which  may  have 
played  a  part. 

In  a  general  way,  the  alimentary  regimen  must  be  as  simple  as 
possible,  in  the  form  of  a  milk-  or  lacto-vegetarian  diet,  at  any 
rate  free  from  all  foods  or  drinks  of  a  stimulating  character  or  of 
difficult  digestion;  it  is  especially  important  to  insist  upon  careful 
chewing,  cleansing  the  teeth  and  keeping  them  in  good  condition, 
counteracting  constipation,  etc.  [The  possibility  that  the  under- 
lying cause  may  be  a  sensitization  to  some  article  of  food,  often 
common  like  eggs  or  milk,  must  not  be  forgotten.] 

The  inherent  nervous  element  of  every  case  of  pruritus  must  be 
treated  by  general  as  well  as  local  measures  and  psychotherapy 
may  have  to  be  utilized. 

Rest  and  a  quiet  mode  of  life  are  indispensable  in  overwrought 
or  excited  patients;  the  majority  of  sufferers  from  pruritus  are 
benefited  by  a  sojourn  in  the  country,  in  the  mountains  or  by  the 
seaside.  It  has  been  observed  that  in  the  poorer  classes,  internment 
in  a  hospital  usually  brings  about  rapid  improvement,  whereas 
their  discharge  is  followed  by  a  prompt  recurrence.  Spinal  punc- 
ture, as  tried  by  Thibierge  and  Ravaut,  is  sometimes  followed  by 
a  sudden  and  permanent  improvement  in  these  cases.  The  modern 
practice  is  to  recommend  various  sero-therapeutic  procedures,  injec- 
tions of  normal  human  serum,  saline  infusions,  auto-hemotherapy, 
hypertonic  sera  with  glucose  or  magnesium  salts,  etc.,  although  the 
indications  are  not  yet  clearly  established. 

Sedative  medicinal  agents,  bromides,  valerian,  antipyrin  and 
its  analogues,  carbolic  acid,  salicylates,  etc.,  are  of  little  value. 
Extract  of  guaco  is  very  unreliable.  As  a  rule,  tonics  are  called 
for;  cod-liver  oil  and  arsenic,  persistently  administered,  are  often 


500         NEURODERMATOSES— PRURITUS  AND  PRURIGO 

very  useful  in  Hebra's  prurigo,  in  the  neurodermatitides  and  the 
prurigo  vulgaris  of  youthful  debilitated  patients. 

Among  physical  agents,  baths  are  often  not  well  tolerated,  even 
with  the  addition  of  bran,  starch,  gelatin,  lime  blossoms,  vinegar, 
etc.  It  is  infinitely  preferable  to  utilize  general  showers  either 
lukewarm  or  barely  warmer  than  the  skin,  applied  with  a  very 
gentle  spray  almost  without  percussion  ("dew-like  douches"),  for 
two,  three  or  even  four  minutes  or  longer,  repeated  once  daily  or 
even  twice  daily  at  the  start. 

Electricity,  in  the  form  of  static  baths,  may  soothe  some  cases  of 
pruritus;  high-frequency  currents  are  even  more  useful. 

Watering-places  suitable  for  patients  with  pruritus  are,  accord- 
ing to  the  desired  end:  Bourboule,  Xeris,  Laxeuil,  Bagneres-de 
Bigorre,  Saint  Gervais,  Loueche,  Ragatz,  etc.;  sometimes,  diuretic 
or  strong  sulphur  springs  are  indicated. 

Local  treatment  is  also  of  great  importance.  Aery  hot  rather 
than  lukewarm  washes  should  be  recommended,  with  one  of  the 
antipruritic  lotions  indicated  further  on  (Therapeutic  Notes,  sec- 
tion 4).  Then  it  is  essential'  to  protect  the  pruriginous  surfaces 
from  light  and  external  irritants;  this  is  accomplished  by  means  of 
occlusive  dressings  or  more  conveniently  through  application  of 
plasters,  zinc  gelatin  or  pastes,  salves  or  varnishes,  according  to  the 
extent  of  the  pruriginous  surfaces  and  the  regions  occupied  by  it. 

In  the  plasters  and  pastes,  various  tars  may  be  advantageously 
incorporated,  especially  tumenol  or  vegetable  tar,  or  antipruritic 
remedies  such  as  menthol,  phenol,  camphor,  various  acids,  etc. 
I  Inguentum  glycerinii  with  tartaric  acid  and  pure  cod-liver  oil  in 
inunctions  or  in  salves  or  plasters,  also  possess  a  certain  value. 

In  circumscribed  pruritus  or  prurigo  two  or  three  radiothera- 
peutic  sessions  (at  a  dose  of  3  to  4  H  every  fortnight)  are  often 
strikingly  successful,  but  their  effect  is  not  always  very  lasting;  in 
case  of  repeated  relapses,  the  applications  must  by  no  means  be 
inconsiderately  repeated,  for  fear  of  radiodermatitis.  High-fre- 
quency currents  act  in  a  less  brilliant  fashion,  but  do  not  involve 
the  same  disadvantages;  scarifications,  filiform  douches  and  douches 
of  superheated  air  may  be  valuable  adjuvants. 

The  essential  point  is  not  to  regard  any  of  these  therapeutic 
procedures  as  a  panacea  and  as  sufficient  by  itself,  but  to  employ 
them  separately  or  together,  according  to  the  case,  devoting  special 
care  to  the  discovery  and  treatment  of  the  individual  conditions 
[the  causative  factor]  in  a  given  case. 

[I  would  particularly  recommend  the  following  plan  of  treat- 
ment for  the  old  patches  of  lichen  simplex  chronicus:  The  patches 
are  vigorously  rubbed  with  a  10  per  cent,  solution  of  caustic  potash 
till  the  surface  begins  to  be  denuded  of  epithelium  and  shows  many 


PRURIGO  501 

oozing  points.  The  burning  sensation  thereby  produced  is  rather 
agreeable  to  the  patient.  The  surface,  washed  with  water  and 
rapidly  dried,  is  then  painted  with  a  solution  of  equal  parts  of 
ichthyol  (or  thigenol)  and  water  and  dusted  thickly  with  an  indif- 
ferent powder.  The  following  day,  treatment  with  the  strong 
salicylic-acid-chrysarobin-tar  ointment  proposed  by  Dreuw  is 
begun;  an  application  is  made  night  and  morning  for  five  days; 
then  follows  a  period  of  four  or  five  days  during  which  the  patient 
washes  the  affected  area  daily  with  soap  and  applies  Lassar's  paste. 
At  the  end  of  this  period  the  discoloration  produced  by  the  Dreuw's 
ointment  will  have  worn  off  and  the  patient  is  ready  to  begin  the 
course  again,  starting  once  more  with  the  caustic  potash  applica- 
tion, which  should  always  be  made  by  the  physician  himself. 

For  the  temporary  relief  of  itching  in  all  forms  of  prurigo,  raying 
with  ultraviolet  light  is  of  decided  value.] 


CH  AFTER    XXV. 
PARASITIC   DERMATOSES. 

Numerous  parasites,  animal  or  vegetable,  may  dwell  on  or  in 
the  human  skin,  giving  rise  to  very  polymorphous  affections. 

The  animal  parasites,  which  are  sometimes  divided  into  epizoa 
and  dermatozoa,  comprise  insects,  acari  and  worms. 

The  vegetable  parasites  or  dermatophytes,  with  the  exception  of  the 
schizomycetes  or  bacteria,  belong  for  the  most  part  to  the  class  of 
niucedinia  or  filamentary  fungi.  Only  the  mucedini;e  which  vege- 
tate in  the  epidermis  and  its  adnexa,  the  hairs  and  the  nails,  will 
be  discussed  in  this  chapter;  the  affections  which  they  cause  may 
be  designated  as  epidermo-mycoses.  As  to  the  true  dermato-mycoses, 
diseases  due  to  dermatophytes  growing  in  the  corium,  a  special 
chapter  will  be  devoted  to  their  discussion  (Chapter  XXVIII). 

DERMATOSES    CAUSED    BY   INSECTS. 

The  parasitic  insects  of  man  live  for  the  most  part  on  the  surface 
of  the  skin;  they  are  epizoa. 

Pediculosis  and  Phthiriasis. — Under  these  names  are  designated 
the  cutaneous  lesions  produced  by  lice. 

Lice  are  insects  of  the  genus  aptera  and  the  family  of  pediculi. 
They  have  a  pyriform  head,  provided  with  a  sucking  rostrum  and 
mandibles  which  can  seize  the  skin;  a  thorax  bearing  six  feet  ter- 
minating in  a  movable  hook;  and  an  abdomen  not  clearly  sepa- 
rated from  the  thorax.  The  females,  more  numerous  and  somewhat 
larger  than  the  males,  lay  a  large  number  of  eggs,  with  a  chitinous 
envelope,  which  are  designated  as  nits.  When  they  hatch,  the 
young  resemble  their  parents  and  undergo  no  metamorphosis. 

Three  kinds  of  lice  are  parasitic  on  man: 

Head-lice. — The  head-louse,  pedicuhts  capitis,  is  about  2  mm. 
long,  of  a  rather  slender  shape,  a  gray  color  marked  with  black 
spots  on  the  border  of  the  abdominal  segments.  It  inhabits  the 
scalp,  especially  in  children  of  both  sexes  and  in  careless  women 
and  rarely  the  beard  in  men.  In  schools  and  asylums  for  pauper 
children,  lice  are  endemic;  in  the  seventeenth  and  eighteenth 
centuries,  they  flourished  even  at  court  in  the  heaped-up  coiffures 
of  the  great  ladies. 


DERMATOSES  CAUSED  BY  INSECTS  503 

By  their  bites,  lice  cause  severe  itching,  scratching  and  excoria- 
tions; but  these  symptoms  may  be  altogether  absent  in  some 
individuals.  Without  proper  care,  these  lesions  become  infected 
and  instead  of  simple  crusted  papules,  impetigo,  yellowish  crusts 
adherent  to  the  hair,  folliculitis  and  abscesses  of  the  scalp,  pyo- 
dermatitis  and  adenitis  at  the  nape  of  the  neck  and  the  lateral 
cervical  regions,  eczematization  of  the  nape  of  the  neck,  the  ears, 
the  face,  etc.,  may  be  seen. 

In  a  social  environment  of  absolute  neglect,  the  head  of  some 
individuals  may  be  found  to  be  covered  as  with  a  cap  formed  by 
matted  hairs  studded  with  innumerable  nits,  teeming  with  lice, 
matted  together  by  infected  crusts  with  a  nauseating  odor;  the 
underlying  scalp  is  bathed  in  pus.  These  extreme  cases  are  desig- 
nated under  the  names  of  trichoma  or  plica. 

The  deep  follicular  inflammations  and  abscesses  may  leave  a 
patchy  cicatricial  alopecia,  which  is  incurable.  The  glandular 
suppurations  of  the  neck  have  been  known  to 
lead  to  anemia,  cachexia  and  generalized  infec- 
tions. 

The  lesions  of  pediculosis  of  the  scalp  begin 
and  predominate  in  the  occipital  region;  a 
pruritus  or  impetigo  localized  at  this  point  is 
suggestive  of  lice  and  these  should  be  looked 
for,  irrespective  of  the  age  or  social  standing 
of  the  patient.  If  they  are  not  readily  dis- 
covered on  parting  the  hair,  at  least  nits  may 
be  found  appearing  as  white  or  grayish  oval  Fig.  151. — Pedicuius 
grains  stuck  fast  to  the  hairs  in  more  or  less     capitis— male.    After 

°        .  ,        ,  ,  t  Kuchenmeister. 

considerable  number. 

Treatment. — In  boys  or  men,  the  hairs  should  be  clipped  close 
to  the  head;  in  young  women,  the  hair  can  almost  always  be  spared. 

In  those  cases  where  the  hair  teems  with  lice,  it  is  customary  in 
the  Saint  Louis  Hospital  to  begin  the  treatment  with  the  application 
on  the  head  during  one  night  of  a  thick  layer  of  vaselin  covered  with 
a  bandage;  the  vaselin  smothers  and  destroys  the  parasites. 

When  the  lice  are  not  so  abundant,  dressings  with  camphorated 
alcohol  left  in  place  for  a  few  hours,  or  washing  with  bichloride  in 
vinegar  (1  :  500),  or  applications  of  powdered  stavesacre  or  pyre- 
thrum  sometimes  suffice  to  kill  the  lice  and  nits.  To  get  rid  of  the 
latter,  it  is  advantageous  after  untangling  the  hairs  to  employ 
a  fine-toothed  comb  dipped  in  hot  vinegar;  the  latter  has  the 
property  of  dissolving  the  cement  which  fastens  the  chitinous 
envelope  of  the  nits  to  the  hairs  and  of  facilitating  their  removal. 
When  there  are  many  crusts,  these  should  be  softened  with  sprays 
or  moist   dressings,  before  removing  them  with  soap  and  water; 


504 


PARASITIC  DERMATOSES 


followed  by  the  application  of  a  sulphur,  naphthol  or  salicylic  acid 
ointment  or  balsam  of  Peru. 

Body-lice. — The  body-louse  or  clothes-louse,  pediculus  corporis, 
sen  rrsiiiut uli,  is  longer,  measuring  nearly  3  mm.,  of  a  yellowish 
white  color  and  its  abdomen  has  no  black  spots.  It  inhabits 
especially  the  clothing  in  contact  with  the  skin,  flannels,  shirts  and 
drawers;  it  is  encountered  among  the  poor,  in  tramps  and  in  out- 
ca>t>  neglectful  of  all  personal  cleanliness.  Unlike  the  head  louse, 
it  attacks  adults  and  old  people  rather  than  children.  Lice  have 
abounded  in  the  trenches  during  the  war.  The  parasites  or  nits 
are  found  especially  in  the  folds,  along  the  seams,  where  they  are 
accumulated  in  severe  cases  of  pediculosis  as  a  dense  mass  of  yel- 
lowish beady  granules,  stuck  to  the  threads  of  the  garment.  They 
are  also  found,  however,  on  the  body  hairs, 
notably  at  the  pubis,  in  90  per  cent,  of  the 
cases  (H.  Bulliard,  1917).  The  clothes-louse 
is  proverbially  prolific;  according  to  Leuwen- 
hoeck,  two  breeding  females  may  in  the 
course  of  two  months  produce  18,000  young 
lice. 

The  bite  of  the  body-louse  gives  rise  to  a 
highly  pruritic  urticarial  papule.  The  itch- 
ing and  scratching  are  especially  severe  in 
the  evening  and  at  night.  A  sort  of  habit- 
uation apparently  becomes  established  in 
inveterately  lousy  subjects,  there  is  no 
longer  an  eruption  and  the  itching  is  not 
conscious,  although  the  scratching  persists 
instinctively,  as  shown  by  the  linear  excori- 
ations following  the  scratch  of  the  nails. 
The  shoulders  and  the  upper  portion  of  the  back  represent  the  site 
of  election  of  this  pediculosis,  next  the  abdomen,  the  loins  and  the 
anterior  aspect  of  the  thighs.  The  face,  the  scalp  and  the  feet  and 
hands  are  exempt.  The  excoriations  may  become  the  starting-point 
of  pyodermatitides. 

[Body-liee  have  been  shown  to  be  carriers  of  typhus  and  possibly 
also  of  "trench-fever."] 

A  long-standing  pediculosis  leads  to  a  rather  peculiar  modifi- 
fication  of  the  skin,  characterized  by  thickening,  a  dry  and  scaly 
epidermis  and  especially  a  dark  pigmentation;  from  this  background 
stand  out  the  white  cicatrices,  recent  excoriations  and  the  innu- 
merable crusts.  This  melanoderma  of  pediculosis  (p.  329)  is  most 
marked  on  the  shoulders  and  the  back,  but  may  become  generalized. 
The  pigmentation  may  be  observed  even  in  the  mouth,  a  proof  that 
scratching  does  not  sufficiently  explain  its  genesis. 


Fig.  152.  —Pediculus 
corporis — female.  After 
Kuchenmeister. 


DERMATOSES  CAUSED  BY  INSECTS  505 

A  differential  diagnosis  in  these  cases  must  be  made  from  Addi- 
son's disease,  in  which  pigmentation  of  the  mouth  is  usually  present. 
But  the  topographical  distribution  of  the  Addisonian  melanoderma 
is  different  and  itching  and  evidences  of  scratching  are  absent. 

Asthenia  and  cachexia  possess  less  diagnostic  value,  being,  like- 
wise encountered  in  the  chronic  pediculosis  of  poverty-stricken 
subjects,  which  here  assumes  the  appearance  of  a  general  disease, 
known  as  Vagabonds'  disease. 

The  differential  diagnosis  from  the  diathetic  forms  of  pruritus 
must  take  into  consideration  the  different  localization  of  the  itching, 
but  is  based  especially  upon  the  presence  or  absence  of  the  parasites 
and  their  nits. 

The  treatment  consists  in  disinfection  of  the  clothing  in  a  steam 
sterilizer  and  in  the  necessary  personal  cleanliness. 

When  no  steam  sterilizer  is  available, 
the  garments  may  be  pressed  out  with 
a  hot  iron  or  exposed  to  fumigations 
with  cinnabar;  these  measures,  com- 
bined with  the  persistent  employment 
of  insecticide  powders,  the  wearing  of 
clean  linen  and  repeated  washing  with 
soap  and  water,  followed  by  parasiti- 
cide inunctions  (see  Therapeutic  Notes, 
section  10)  may  be  sufficient. 

Pediculus  Pubis.  —  Phthirius  ingui- 
nalis,  popularly  known   as  the  crab- 
louse,  is  nearly  as  broad  as  it  is  long, 
vaguely  resembling  a  crab;  it  lives  an        FlG   153._pedicuius  pubis. 
the  hairy  regions  of  the  pubis  and  After  Schmarda. 

vicinity,  where  it  clings  to  two  neigh- 
boring hairs  by  means  of  the  curved  hooks  of  its  feet.    In  hairy 
men,  it  may  invade  the  thighs,  the  entire  trunk  and  the  beard;  in 
both  sexes  it  infests  the  axillae;  in  children  and  young  women  it 
may  even  lodge  on  the  eyelids,  causing  a  blepharitis  phthiriasica. 

Crab-lice  are  usually  acquired  through  sexual  intercourse,  but  also 
through  indirect  contagion,  in  water-closets,  or  infested  bedding  in 
hotels.  It  has  often  been  noted  that  this  parasite  is  less  common 
in  the  very  lowest  class  where  personal  cleanliness  is  absent,  than 
in  the  middle  and  even  in  the  wealthy  class. 

Pediculus  pubis  gives  rise  to  a  very  variable  amount  of  itching  in 
different  individuals  and  to  scratching  with  its  usual  sequela?. 
This  etiology  must  be  kept  in  mind  in  considering  an  eczema  or 
pyodermatitis  of  the  regions  mentioned.  Together  with  the  crab- 
lice,  nits  will  be  discovered  sticking  to  the  hairs  near  their  base. 

A  peculiar  consequence  of  the  bite  of  phthirius  is  the  appearance 


506  PARASITIC   DERMATOSES 

of  blue  spots  or  shaded  spots  [taches  bleues,  taches  ombrees,  macules 
ceruleoe],  seen  especially  on  the  abdomen,  the  flanks  and  the  thighs. 
Formerly  regarded  as  symptomatic  of  undetermined  or  even  of 
typhoid  fever,  these  spots  have  been  traced  to  their  true  cause  by 
Falot,  Mourson  and  the  experiments  of  Duguet  [though  their 
pathogenesis  is  still  unknown]. 

Treatment. — The  classical  treatment  with  inunctions  of  blue 
ointment — which  should  be  rejected  on  account  of  the  mercurial 
eruptions  so  frequently  (and  stomatitis  occasionally]  caused  by  this 
salve — is  preferably  replaced  by  inunctions  with  yellow  precipitate 
ointment  of  5  or  10  per  cent.,  or  a  white  precipitate  or  naphthol 
salve  or  balsam  of  Peru.  Washing  with  bichloride-alcohol  (1  :  500) 
is  also  effective.  [A  salve  containing  three  parts  of  ammoniated 
mercury  ointment  and  one  part  of  blue  ointment  is  safe  and  effective.] 
In  phthiriasis  of  the  eyelids,  Jullien  recommended  the  removal  of 
the  parasites  one  by  one  by  means  of  a  forceps. 

Other  Sucking  Insects.  —  Fleas.  —  These  are  of  various  kinds, 
each  attacking  a  different  animal.  The  human  flea,  pulex  irritans, 
lays  its  eggs  in  the  dust  of  floors,  etc.  Its  bite  produces  a  character- 
istic lesion;  a  hemorrhagic  point  surrounded  by  a  lenticular  zone  of 
erythema;  this  disappears  in  a  few  hours,  whereas  the  central  ecchy- 
mosis  persists  several  days.  In  children  and  in  persons  with  an 
irritable  sensitive  skin,  an  urticarial  wheal  forms  at  the  onset; 
[and  in  some  cases,  the  wheal  on  subsiding  leaves  behind  a  papule 
which  itches  periodically  for  several  days].  Some  individuals  are 
not  attacked  by  fleas.  In  cases  of  extreme  abundance  of  fleas,  in 
rag-pickers  for  example,  the  entire  skin  may  be  dotted  with  minute 
red  spots  resembling  purpura. 

Fleas  may  act  as  carriers  of  the  germs  of  severe  infectious  diseases; 
there  is  reason  to  believe  that  these  insects  convey  Bubonic  plague 
from  rats  to  man. 

Pulex  Penetrans  or  Jigger. — This  variety,  Rynchoprion  penetrans 
or  Dermatophilus  penetrans,  occurs  in  tropical  America  and  in 
Africa;  the  female  burrows  into  the  cutis,  especially  on  the  toes  and 
soles  of  the  feet,  where  it  grows  to  the  size  of  a  pea,  causing  a 
furunculoid  abscess.  The  loss  of  one  or  several  toes,  gangrene  and 
tetanus,  may  be  the  consequence  of  this  "dermatophilia." 

Bed-bugs. — The  bed-bug,  cimex  lectularius,  lives  and  multiplies 
in  wooden  bedsteads,  in  cracks  of  wainscoting  and  in  upholstery. 
At  night  these  animals  sally  forth  from  their  hiding  place  and  bite 
the  sleeper,  producing  red  urticarial  elevations  on  the  skin,  some- 
times with  extensive  edematous  swelling  and  a  painful  burning 
sensation.  They  are  suspected  of  being  possible  carriers  of  Oriental 
boil,  Bubonic  plague,  the  trypanosomiases  and  Koch's  bacillus. 


DERMATOSES  CAUSED  BY  AC  Alii  507 

Mosquitoes. — This  name  is  applied  to  an  entire  series  of  species 
of  culex,  simulia,  stegomya,  anopheles,  etc.,  distributed  in  all  countries, 
especially  hot  countries.  The  female  sting  the  parts  accessible  to 
them,  especially  at  night,  producing  a  rather  persistent  urticarial 
swelling,  particularly  after  scratching. 

Great  interest  is, attached  to  these  insects  since  it  is  known  that 
their  various  kinds  serve  as  intermediary  hosts  and  transmitters 
for  the  parasites  of  malaria  (anopheles),  of  yellow  fever  (stegomya), 
of  filariasis  and  perhaps  also  of  pellagra  (simulides)  and  of  leprosy. 
[The  simulium  theory  of  pellagra  is  no  longer  entertained.]  Through 
the  systematic  destruction  of  mosquitoes  immense  tracts  of  land 
have  been  redeemed. 

The  treatment  of  the  bites  of  fleas,  bed-bugs  and  mosquitoes 
consists  in  applications  of  alcoholic  solutions  of  menthol  or  carbo- 
lized  vinegar,  dilute  ammonia,  collosol,  naphthalan,  etc.,  followed 
by  bland  powders.  General  prophylaxis,  namely  the  destruction 
of  the  insects,  often  presents  serious  difficulties.  Protection 
against  mosquito  bites  is  secured  through  the  employment  of 
mosquito-netting  [or  by  rubbing  the  exposed  parts  of  the  skin 
with  oil  of  citronella];  in  a  closed  room,  pyrethrum  may  be 
burned. 

DERMATOSES  CAUSED  BY  ACARI  (MITES). 

The  parasitic  acari  of  men  are  in  part  true  dermatozoa,  living  in 
the  horny  epidermis,  such  as  acari  or  sarcoptes,  or  in  the  pilo- 
sebaceous  follicles,  such  as  demodex;  and  in  part  epizoa,  such  as 
ticks,  etc. 

Scabies. — Scabies  is  a  contagious  parasitic  dermatosis,  caused 
by  an  acarus,  the  Sarcoptes  scabiei  (Latreille),  variety  hominis 
(Megnin) .  It  is  extremely  pruritic  and  is  characterized  essentially 
by  a  special  dermatological  lesion,  the  burrow;  and  by  polymorphous 
accessory  eruptions,  having  a  regional  and  symmetrical  distribu- 
tion. 

The  ancients,  confusing  scabies,  psora  or  the  itch,  with  the  pruri- 
gos, interpreted  it  as  a  diathetic  disease,  subject  to  metastases, 
which  was  treated  by  venesection  and  blood  purifiers.  It  was  in 
vain  that  the  parasite  was  pointed  out  by  Mouffet  (1634),  C. 
Bonomo  (1687),  Wichmann  (1786).  The  truth  was  not  established 
until  Renucci  (1834),  a  student  from  Corsica,  demonstrated  in  public 
in  the  clinics  of  Alibert,  the  sarcoptes  which  his  countrywomen  had 
taught  him  to  know  and  extract  (Fig.  154). 

Symptoms. — The  itch  is  observed  in  all  social  strata  and  at  any 
age;  it  is  more  common,  however,  among  prostitutes  and  paupers 
living  in  crowded  quarters. 


508 


PA  RA  SI  TI C  I)  E  R  MA  TOSES 


The  symptoms  do  not  appear  until  after  a  latent  period,  averaging 

ten  days. 

The  eruption   is  localized  or  predominates  in  certain  areas  of 
predilection,  which  should  he  systematically  explored  in  all  patients 


Fig.  154. — Sarcoptes  scabiei,  male  and  female.  Reduced  from  Furstenberg,  after 
Murray. 


Fig.   155.—  Scabies. 


complaining  of  nocturnal  itching.  These  are:  the  hands  (Fig.  155), 
the  interdigital  spaces,  the  lateral  aspects  of  the  fingers,  the  wrists, 
more  particularly  their  ulnar  side,  the  elbows,  the  anterior  wall  of 


DERMATOSES  CAUSED  BY  ACARI 


509 


the  axilla,  the  ankles  and  the  heels;  in  men,  the  sheath  of  the  penis 
and  the  glans;  in  women,  the  breasts;  in  children,  the  buttocks. 
But  the  lesions  may  also  occupy  any  other  region,  excepting  the 
head  which  always  escapes  and  the  neck  and  back  which  are  usually 
free.    This  topography  in  itself  is  characteristic. 

The  itch,  however,  has  a  pathognomonic  feature,  the  burrows. 
These  are  narrow  grayish  tracts,  as  if  traced  with  the  point  of  a 
needle,  taking  a  curved  or  sinuous  course  which  does  not  correspond 
to  the  folds  of  the  epidermis.  They  have  a  length  of  2  to  3  mm.  or 
more;  Dubreuilh  observed  a  burrow  4  cm.  long  on  the  foot.  These 
burrows  represent  the  passages  dug  by  the  parasite  in  the  horny 
ayer  of  the  epidermis.  They  are  often  dotted  with  black  points 
which  indicate  the  exit  orifices  of  the  newly  hatched  larvse.     Their 


Fig.  156.— Scabies  burrow.  The  shred  of  horny  epidermis  containing  this  burrow 
was  ablated  with  a  razor;  it  is  shown  from  its  lower  or  deep  aspect.  A,  entrance 
orifice;  B,  black  matter,  excreta;  C,  opening;  D,  ova;  E,  acarus.    X  50. 


general  color,  which  is  darker  in  laborers  and  uncleanly  persons,  is 
partly  referable  to  the  excreta  left  by  the  sarcoptes  and  also  to 
deposits  of  dust  and  dirt.  White  burrows  may  be  found  in  the 
better  classes. 

One  of  the  extremities  of  the  burrow,  its  head,  is  marked  by  a 
small  nacreous  elevation,  the  acarus  eminence  of  Bazin;  this  is  a 
tiny  deep  vesicle  which  forms  in  the  vicinity  of  the  sarcoptes.  The 
animal  may  be  extracted  by  tearing  off  the  roof  of  the  burrow  with 
a  needle  and  catching  it  in  the  cul-de-sac;  or  the  entire  burrow  may 
be  excised  by  means  of  fine  curved  scissors  or  a  razor  (Fig.  156). 
The  burrows  are  most  easily  discovered  on  the  fingers,  the  wrists, 
the  elbows,  the  penis,  the  heels,  in  general  where  there  is  a  thick 
epidermis, 


510 


I'.  1  /,'.  1  SI  Til  •   DERMA  TOSES 


The  other  lesions  of  scabies  are  accessory  or  secondary  erup- 
tions, of  variable  characters  and  abundance.  At  the  onset,  these 
consist  of  spots  of  erythema  or  urticaria;  next,  of  punctate  or 
linear  excoriations  produced  by  scratching,  crusted  miliary  papules, 
vesicles  of  dysidrotiform  eczema,  or  ordinary  eczema  scattered  or  in 
patches  (scabietic  eczema);  and  finally,  of  various  pyodermatitides 
—impetigo,  folliculitis  and  ecthyma  (scabietic  ecthyma),  suppu- 
rating or  dried  into  crusts  which  are  scattered  by  the  scratching  and 
may  even  be  transported  to  the  face.  These  lesions  may  become 
complicated  by  lymphangitis,  adenitis  and  cellulitis.  Eczema  of  the 
nipples  and  areolae  in  women  ( Fig.  1 57 1  is  always  due  either  to  scabies 
or  to  pregnancy.  The  polymorphism  of  the  scabies  eruptions  is  a 
characteristic  feature,  but  their  topographical  distribution  is  even 
more  so. 


The  itching  of  scabies  is  usually  almost  intolerable.  Its  principal 
attribute  is  its  nocturnal  character;  it  is  especially  pronounced  at 
the  moment  of  retiring,  but  lasts  until  morning,  often  causing  com- 
plete insomnia.  This  time  is  the  period  of  activity  for  the  acari. 
The  itching  is  more  or  less  localized  or  general.  In  some  individuals, 
scratching  is  unconscious;  they  scratch  and  flay  themselves  without 
being  aware  of  it.  Pruritus  may  be  absent  although  this  is  very  rare. 
[A  moderate  degree  of  eosinophilia  is  commonly  present  in  the 
blood  of  scabietics.] 

Etiology. — The  fertilized  female  of  Sarcoptes  scabiei  is  alone  re- 
sponsible for  digging  the  burrows  and  causing  the  symptoms  of 
scabies.  It  has  the  shape  of  a  flattened  oval  and  measures  one-third 
or  one-fourth  of  a  millimeter;  it  is  therefore  visible  to  the  nuked  eye 
as  an  opaque  whitish  point.  The  anterior  two  pairs  of  its  eight  feet 
are  furnished  with  cupping  pads,  the  posterior  two  pairs  with  long 
bristles.  The  males,  which  do  not  inhabit  the  burrows,  are  much 
rarer  and  more  difficult  to  discover;  they  are  only  half  the  size  of 


DERMATOSES  CAUSED  BY  ACARI  511 

the  females  and  their  fourth  pair  of  feet  also  is  furnished  with  cup- 
ping pads. 

The  ova,  which  the  female  drops  behind  her  in  the  burrow,  meas- 
ure 0.16  mm.  x  0.10  mm.  and  are  more  developed  in  proportion  to 
their  nearness  to  the  entrance  orifice.  They  hatch  in  four  to  eight 
days  and  the  young  leave  the  burrows  through  the  openings  to 
settle  elsewhere. 

The  sole  cause  of  scabies  is  the  transmission  of  the  parasite.  There 
exist  neither  individual  immunity  nor  predisposition.  In  view  of 
the  habits  of  the  sarcoptes,  the  contagion  occurs  almost  exclusively 
at  night.  It  is  necessary  for  an  impregnated  female  to  pass  from  an 
infected  to  a  healthy  subject.  This  transmission  is  practically 
inevitable  in  persons  who  share  the  same  bed,  hence  family  epidemics 
and  the  frequent  venereal  origin  of  scabies.  Contagion  is  possible 
through  unchanged  bed-sheets  in  hotels,  through  clothing,  through 
sheets  in  sleeping-cars;  it  may  very  exceptionally  result  from  con- 
tact in  daytime;  it  is  very  doubtful  if  it  can  occur  through  tools, 
books,  etc. 

[Scabies  is  one  of  the  commoner  skin  diseases.  In  the  statistics 
of  American  Dermatological  Association  it  averaged  about  5  per 
cent,  of  all  cases  during  a  period  of  thirty  years.  In  the  first 
decade  of  this  century,  however,  there  was  a  great  increase  in  the 
incidence  of  the  disease  and  in  1908  it  constituted  10  per  cent,  of 
all  skin  diseases  seen — a  veritable  epidemic.  In  general,  scabies  is 
somewhat  more  frequent  in  European  countries  than  in  America.] 

Prognosis. — Scabies  never  heals  spontaneously.  In  some  nervous 
individuals  it  may  end  in  marasmus,  on  account  of  the  pruritus 
and  insomnia.  Albuminuria  is  said  to  be  not  very  rare  in  patients 
suffering  from  the  itch;  it  is  attributed  either  to  the  toxins  of  the 
sarcoptes  or  to  nephritis  caused  by  the  microbes  of  suppuration. 

In  certain  villages  of  Norway,  Brittany,  Italy,  scabies  was 
endemic  for  a  time;  it  persisted  throughout  life,  usually  without 
causing  severe  symptoms. 

In  the  course  of  febrile  diseases,  the  symptoms  of  scabies  as  a 
rule  entirely  disappear,  recurring  as  soon  as  convalescence  sets  in. 

Diagnosis. — The  topography  and  polymorphism  of  the  eruptions, 
the  nocturnal  pruritus  and  the  contagiousness,  make  the  diagnosis 
probable;  the  demonstration  of  burrows  or  of  acari  or  their  ova 
makes  it  positive. 

The  essential  point  is  to  keep  scabies  in  mind,  whatever  the 
environment  of  the  patient;  not  allowing  one's  self  to  be  deceived 
by  the  eruptions  of  strophulus,  prurigo,  dysidrosis,  pediculosis, 
eczema  or  pyodermatitis. 

A  real  difficulty  results  from  the  obsession  known  as  acarophobia, 
or  fear  of  the  itch;  this  is  observed  in  persons  who  have  heard  of  it 


512  PARASITIC  DERMATOSES 

and  especially  in  those  who  have  had  the  disease  and  been  treated 
for  it.  When  pruritus  and  eczema  persist,  after  treatment  by  the 
method  called  "la  frotte"  to  be  described  presently,  baths  and 
soothing  creams  should  be  recommended  instead  of  hastening  to 
resume  the  treatment,  unless  new  burrows  are  discovered. 

Treatment. — In  order  to  cure  the  itch,  it  suffices  to  destroy  the 
parasite  and  its  ova;  no  internal  treatment  of  any  kind  is  required. 

The  classical  "frotte"  of  the  Saint  Louis  Hospital  constitutes  the 
most  rapid  treatment. 

It  begins  with  rubbing  the  whole  body  vigorously  with  soft  soap 
for  twenty  to  thirty  minutes  and  continuing  the  friction  in  a  warm 
bath  for  another  hour,  in  order  to  open  all  the  burrows;  during  this 
time  the  patient's  clothes  are  disinfected  in  a  steam-sterilizer. 
Xext,  the  body  is  thoroughly  rubbed  with  the  Helmerich-Hardy 
ointment,  which  is  left  on  until  the  next  day,  when  a  full  bath  is 
administered. 

Less  irritative  sulphur  ointments  may  be  utilized,  according  to 
the  formulas  of  Bourguignon  or  Fournier  (for  examples  see  Thera- 
peutic Notes,  §10). 

The  "frotte"  treatment  must  not  be  applied  to  young  children, 
pregnant  women,  patients  with  a  very  delicate  skin  or  those  suffer- 
ing from  extensive  pyodermatitis.  In  such  cases  other  substances 
may  be  utilized,  such  as  balsam  of  Peru,  styrax,  naphthol,  etc., 
which  have  been  tried  and  approved  but  which  must  be  employed 
in  moderate  strength  for  eight  to  ten  days  in  succession,  at  night, 
preferably,  after  washing  with  soap;  disinfection  of  the  clothing  is 
not  indispensable. 

("are  must  be  taken  always  to  examine  the  bedfellow  and  children 
of  the  patient,  as  well  as  to  treat  on  the  same  day  all  who  have  been 
discovered  to  be  infected. 

Animal  Scabies. — Scabies  Norwegica  or  crustosa,  described  by 
Danielssen  and  Boeck  in  lepers,  also  occurring  in  Germany  and 
various  other  countries,  gives  rise  to  thick  and  prominent  incrus- 
tations which  may  occupy  the  entire  body,  including  the  back  and 
the  face.  In  all  probability  this  condition  represents  not  simply  an 
inveterate  common  itch,  but  a  special  parasitical  variety,  as  was 
maintained  by  Megnin,  the  sarcoptes  of  wolves. 

Other  animal  itches,  caused  by  sarcoptes  other  than  the  human 
variety,  are  very  rarely  transmitted  to  man.  The  absence  of 
burrows  has  almost  always  been  expressly  noted.  The  eruption  is 
miliary  or  polymorphous,  diffuse  and  pruriginous.  These  abnormal 
itches  may  be  derived  from  cats,  birds,  dogs,  sheep,  goats,  camels, 
pigs,  etc.  They  are  usually  very  readily  curable  or  even  subside 
spontaneously. 

The  most  noteworthy  and  serious  form  is  equine  scabies,  of  which 


DERMATOSES  CAUSED  BY  AC  Alii  513 

I  observed  an  example  almost  identical  with  the  case  published  by 
Besnier  and  Megnin  in  1892.  The  appearance  was  that  of  a  pity- 
riasis rubra,  completely  generalized;  the  sarcoptes  were  demon- 
strable by  thousands  in  the  scales  and  crusts;  there  were  no 
burrows. 

Other  Parasitic  Acari. — Demodex  Folliculorum. — This  is  a  worm- 
like acarus,  measuring  from  0.3  mm.  to  0.4  mm.,  whose  cephalo- 
thorax  is  provided  with  a  mouth  and  four  pairs  of  rudimentary  feet ; 
the  abdomen  resembles  the  finger  of  a  glove  and  shows  fine  trans- 
verse striations. 

This  parasite  inhabits  the  sebaceous  follicles,  especially  the 
mouths  of  the  large  sebaceous  glands  of  the  face,  with  its  head 
directed  inward;  a  large  number,  ten  or  twelve,  may  be  found  in 
the  same  follicle. 

It  has  the  reputation  of  being  non-pathogenic,  causes  no  inflam- 
mation and  certainly  plays  no  part  in  comedo  and  acne  vulgaris. 
It  was  held  responsible,  however,  by  Dubreuilh,  in  a  case  of  localized 
pigmentation;  personally,  I  have  seen  it  so  abundantly  present  in 
the  horny  prominences  of  a  lichen  spinulosus  that  I  was  tempted  to 
attribute  an  irritative  influence  to  it  in  this  case. 

Certain  observations  of  Borrel  would  seem  to  suggest  that  the 
demodex,  or  analogous  acari,  might  intervene  in  the  etiology  of 
epitheliomas  of  the  face,  as  irritants  or  as  carriers  of  a  hypothetical 
contagium,  as  well  as  in  the  etiology  of  leprosy.  A  disease  of  dogs, 
known  as  follicular  mange,  not  transferable  to  man,  is  due  to  a 
variety  of  demodex. 

Leptus  Autumnalis  (rouget  or  aoutat)  is  the  larva  of  a  trombidium 
holosericum  which  lives  on  vegetables,  notably  on  beans,  wild  grapes 
and  many  varieties  of  grasses.  Certain  regions  have  for  a  long  time 
been  infested  with  it;  at  present  it  is  spreading  in  numerous  locali- 
ties in  the  vicinity  of  Paris.  These  mites  flourish  in  the  summer- 
time and  attack  those  visiting  fields  or  gardens;  attaching  them- 
selves to  the  legs,  the  thighs,  the  waist  and  the  axillae,  especially 
where  a  band  such  as  a  garter  or  belt,  etc.,  retains  them;  but  they 
are  found  even  on  the  ears  and  the  face.  They  cause  a  frightfully 
itching  urticarial  papule  which  the  patients  scratch  off  with  their 
nails.  Careful  inspection,  preferably  with  a  lens,  reveals  the  para- 
site in  the  form  of  a  blood-red  dot,  measuring  from  \  to  ^  mm.  in 
the  follicular  mouth  of  a  hair;  often  several  are  seen  together. 
Under  the  microscope,  they  resemble  cheese-mites,  but  of  a  red 
color. 

Infection  may  be  guarded  against  by  rubbing  with  tincture  of 
benzoin  or  oil  of  cade.    The  treatment  of  the  very  distressing 
eruption  caused  by  the  parasite  consists  in  washing  with  benzene 
or  applications  of  Peru  balsam  or  tincture  of  iodin. 
33 


514  PARASITIC  DERMATOSES 

Ixodes  (Ticks).- — The  most  common  (in  Europe)  is  i.nxles  ricinus, 
the  wood-tick,  a  large  brownish  acarus  which  in  the  fasting  state 
measures  from  3  to  4  mm.;  its  body  becomes  globular  and  con- 
siderably swollen  when  the  animal  is  gorged  with  blood.  It  attacks 
dogs,  cattle  and  large  game,  but  rarely  human  beings. 

Argas. — Argas  reflexus  marginatus,  closely  related  to  the  ixodes, 
is  of  similar  size  and  has  the  appearance  of  a  small  gray  shield.  It 
is  a  pigeon-parasite  and  infests  dove-cots.  When  it  accidentally 
bites  man,  a  very  painful  extensive  phlegmonous  edema  has  been 
known  to  follow,  with  vesiculation  or  generalized  urticaria,  dis- 
tress, tachycardia  and  digestive  disturbances;  these  symptoms  are 
undoubtedly  due  to  inoculation  with  septic  germs.  Other  species 
of  argas  and  ornithodorus  may  transmit  to  man  various  pathogenic 
agents,  notably  the  spirochete  of  "tick-fever,"  etc. 

Pediculoides  Ventricosus. — In  laborers  engaged  in  unloading 
exotic  cereals  from  various  countries  and  on  the  boats  which  carry 
these  cargoes,  one  may  observe,  sometimes  in  epidemic  form,  an 
extremely  pruritic  erythemato-papular  eruption  caused  by  the 
acarus  which  bears  this  name.  It  measures  from  120  to  200  fx. 
in  length  by  70  to  80  /jl.  in  width.  Washing  with  dilute  vinegar 
suffices  to  cure  these  patients.  [The  parasite  is  conveyed  in  wheat 
straw  and  considerable  endemics  of  an  urticarial  disease  have 
occurred  in  consecmence  of  the  use  of  the  infested  straw  for  making 
cheap  mattresses.] 


DERMATOSES  CAUSED  BY  WORMS  AND  LARWE. 

Among  the  numerous  parasitic  worms  of  man,  only  one  really 
lodges  in  the  skin,  namely  filaria  medinensis. 

Filaria  Medinensis  or  Dracunculus. — This  is  a  nematode  worm 
occurring  in  many  tropical  countries,  notably  in  Western  Africa 
((juiiwa-worm). 

The  adult  female  is  filiform  and  from  GO  to  SO  cm.  long;  it  remains 
rolled  up  in  the  frequently  single  abscesses  which  its  presence 
produces,  usually  on  the  feet  or  legs.  The  filaria  is  ingested  by 
drinking  stagnant  water  in  which  the  embryos  have  been  deposited 
and  have  penetrated  into  a  small  crustacean,  a  cyclops  (Manson) 
[which  serves  as  an  intermediate  host].  It  is  not  until  a  year  later 
that  a  fecundated  female  filaria  emerges  at  the  skin. 

In  place  of  the  classical  treatment,  namely  extraction  of  the 
worm  by  pulling  and  rolling  it  up  on  a  small  stick,  in  which 
rupture  is  a  common  and  dangerous  occurrence,  it  has  been 
recommended  to  inject  a  solution  of  bichloride,  1  to  1000,  in  the 
vicinity  of  the  worm,  which  dies  and  is  then  more  easilv  extracted. 


EPIDERMOMYCOSES  515 

Filarial  elephantiasis  (Chapter  XVIII)  cannot  be  interpreted 
simply  as  a  parasitic  dermatosis. 

Various  eruptions  have  been  reported  as  due  to  other  kinds  of 
filaria.  Craw-craw  is  a  pruritic  papulo-vesicular,  later  ulcerative 
dermatosis  of  the  feet  and  legs,  observed  in  Western  and  Central 
Africa.  It  is  imperfectly  known  and  has  been  referred  to  micro- 
filaria (O'Neil),  larvse  (Nielly),  etc. 

Pani-ghao,  or  ground-itch  of  Assam  and  the  United  States,  is  a 
papulo-vesicular  and  pruritic  dermatitis  due  to  the  larvse  of  ankyl- 
ostoma  duodenale  [hook-worm]  having  penetrated  into  the  skin  of  the 
feet  or  legs. 

Cysticercus  Cellulosce. — This  parasite  is  sometimes  present  in  the 
subcutaneous  tissue  of  man  as  well  as  pigs  and  is  apparently  more 
frequent  in  Germany  than  in  France  [and  very  rare  in  America]. 
The  cysticercus  cellulosse  is  the  vesicular  form  of  tenia  solium.  The 
parasites  appear  as  small  and  hard,  round  nodules,  the  size  of  a 
large  cherry  pit,  present  in  more  or  less  considerable  number  in  the 
hypoderm  or  more  deeply,  causing  neither  pain  nor  inflammatory 
reaction.  They  contain  a  clear  fluid  and  a  scolex  provided  with  its 
hooks  and  suckers.  The  tapeworm  whose  ova  have  caused  the 
infection  not  infrequently  inhabits  the  intestine  of  the  patient  him- 
self or  that  of  a  person  in  his  environment. 

The  treatment  requires  the  extirpation,  or  better,  electrolysis  of 
each  nodule  with  the  positive  pole. 

Larva  Migrans. — Under  this  name  is  designated  the  parasite  of 
a  very  peculiar  affection  named  creeping  disease,  pointed  out  by 
H.  G.  Lee,  in  1874  and  1884.  It  is  characterized  by  a  red  line, 
1  to  3  mm.  wide,  irregularly  winding  and  undulating  on  the  skin, 
sometimes  forming  knots  and  loops;  its  extremity  advances  from 
1  to  10  cm.  daily.  This  dermatosis  is  not  uncommon  in  Russia. 
It  is  difficult  to  seize  the  parasite;  it  is  a  very  motile,  black-headed, 
1  mm.  long  larva  of  a  gastrophilus  or  horse-fly.  The  affection  may 
be  cured  by  tincture  of  iodin  or  bichloride  of  mercury  [by  injections 
in  front  and  around  the  head  of  the  advancing  line.] 

Various  cutaneous  myases  due  to  the  larvse  of  flies  (oestridse  and 
muscida?)  are  related  affections. 

EPIDERMOMYCOSES. 

The  epidermomycoses  are  caused  by  mucedinese  and  are  purely 
local  affections,  without  reaction  upon  the  general  health. 

Among  the  thread  fungi  which  are  entitled  to  the  name  of  epi- 
dermophytes,  some  affect  preferably  the  scalp  (tinea  XX)  or  the 
beard  (sycosis,  XIX)  and  the  nails^ (onychomycoses  XXI). 

The  same  species  may  also  vegetate  upon  the  hairless  skin,  while 


516  PARASITIC  DERMATOSES 

others  affect  it  exclusively;  in  this  way  the  erythematosquamous  ( V) 
and  eczemaUform  mycoses  (IV)  originate. 

Favus. — Under  this  name  is  designated  an  epidermomycosis  due 
to  the  achorion  Schonleinii. 

Favus,  formerly  confused  like  the  tineas  with  porrigo  and  impetigo, 
was  separated  by  Biett  and  the  brothers  Mahon.  Its  parasite  was 
discovered  by  Schonlein  of  Zurich,  in  L839,  well  described  by 
Gruby   and   christened   by  Remak. 

Favus  is  essentially  a  rural  disease,  is  not  limited  to  children  and 
produces  crusts  and  cicatrices;  a  spontaneous  cure  is  exceptional. 
These  features  differentiate  it  from  the  other  epidermomycoses. 

The  characteristic  eruptive  lesion  of  favus  is  the  scUtulum,  a 
saucer-shaped  crust  2  to  4  mm.  in  diameter,  thick  in  proportion, 
of  a  sulphur  yellow  color,  usually  pierced  by  a  thick  or  downy  hair. 


#1- 

Fig.   158. — Favus;  spores  and  separate  mycelic  fragments.      X  900. 

The  cup  or  scutulum  originates  as  a  mass  of  white  matter  in  a 
follicular  funnel  and  at  first  resembles  a  small  pustule.  This  mass 
grows  and  extends  in  the  horny  layer,  part  of  which  covers  it  for  a 
certain  length  of  time;  then  it  dries,  becomes  depressed,  yellow  and 
friable.  In  three  weeks  the  cup  attains  a  diameter  of  '.\  mm.,  and 
may  grow  still  larger.  More  frequently,  neighboring  cups  of  differ- 
ent si/es  become  agglomerated  into  an  irregular  roughened  mass 
which  has  been  compared  to  a  honeycomb  (favus)  and  has  a  mousy 
odor. 

The  material  of  a  favus-cup  is  easily  broken  up  into  a  grayish 
dust.  Examined  under  the  microscope,  in  a  drop  of  40  per  cent, 
caustic  potash  or  of  formic  acid,  the  cup  appears  composed  of  spores 
in  great  numbers  and  short  tubes  of  mycelium  (Fig.  158).  The 
mycelial  segments,  from  4  to  15  fx.  long,  from  .">  to  7  ix.  wide, 
are  of  irregular  form,  present  short  lateral  branches  and  often  ter- 
minate in  a  row  or  tuft  of  cubical  members  or  spores.  These  spores 
are  rounded,  oval  or  irregular,  and  of  varying  diameter;  they  con- 
sist like  the  tubules  of  a  granular  protoplasm  and  a  not  easily 
differentiated  membrane, 


SPIDER  MOM  YC  'OSES 


117 


The  achorion  is  characterized  by  its  abundance  as  well  as  by  the 
irregularity  and  clumsiness  of  its  forms. 

In  a  cross-section  of  a  favus  cup  (Fig.  159)  which  is  made  up 
entirely  of  parasites,  one  finds  at  the  base,  slender  imperfectly 
partitioned  threads;  in  the  middle  layer,  thick  sporulated  threads, 
at  the  surface,  short  members  and  spores;  the  whole  may  be 
covered  with  lamellae  of  horny  epidermis. 

Malassez  observed  in  a  case  of  favus  that  the  mycelial  tubes 
penetrated  under  the  cup  as  far  as  the  connective  tissue  of  the  cutis, 
without  exciting  a  special  inflammatory  reaction.  His  specimens, 
which  I  was  enabled  to  study,  are  convincing  and  have  been  endorsed 
by  all  histologists  who  have  seen  them;  but  such  a  penetration  is 
exceptional  and  has  never  again  been  demonstrated  by  myself  or 
by  others.  It  certainly  does  not  explain  the  inflammatory  reaction 
caused  by  favus  and  the  cicatrices  which  it  leaves  behind. 


Fig.   159. — Favus;  cross-section  through  a  cup  imbedded  in  the  epidermis.      X  60. 


I  have  personally  described  with  J.  Halle  (1910),  under  the  name 
of  granuloma  favosum,  intradermic  tuberculoid  nodules  surrounded 
by  a  ring  of  giant  cells,  found  on  the  scalp  in  a  case  of  favus.  These 
are  very  rare  and  are  probably  due,  like  the  trichophytic  granulomas 
of  Majocchi,  to  the  destruction  of  hair  follicles. 

In  a  scale  of  epidermic  favus  without  cups  there  are  found  not 
only  a  very  irregularly  partitioned  mycelium  but  also  collections  of 
spores  which  are  not  seen  in  herpes  circinatus  trichophyticus. 

The  dull  and  discolored  hairs,  in  favus,  are  not  brittle  like  tricho- 
phytic hairs,  because  the  parasite  is  much  less  abundant  in  the 
favus  hairs.  One  finds  in  them  a  variable  number  of  greatly  twisted 
tubules,  either  thick  and  sporulated,  or  slender  and  more  rectilinear, 
composed  of  segments  from  12  to  15/x  in  length,  dichotomized  at 
an  acute  angle  and  generally  surrounded  with  air-bubbles,  which 
at  once  indicate  their  presence. 


518  PARASITIC  DERMATOSES 

In  favus  of  the  nails,  the  ungual  cells  are  dissociated  by  irregular, 
slender  or  very  bulky  filaments  or  by  spores;  this  appearance  is  not 
characteristic. 

Cultures  of  a  particle  of  a  cup  or  of  the  root  of  a  favus  hair,  on 
peptonized  agar,  yield  in  three  or  four  days,  at  a  temperature  of  90°  F., 
a  star  of  white  radiating  filaments;  by  the  end  of  three  weeks  this 
has  become  an  irregular  patch,  2  to  4  cm.  in  diameter,  with  an 
irregular  undulating  surface,  of  a  yellowish  gray  color,  smooth  or 
covered  with  a  scanty  whitish  down;  its  periphery  sends  out  branch- 
ing and  nodular  radiations. 

The  achorion  Schonleinii  belongs  botanically  to  the  genus  oospora; 
it  is  responsible  for  practically  all  cases  of  human  favus.  Due  to 
the  remarkable  investigations  of  Sabrazes,  Bodin  and  others,  we 
know  at  the  present  day  several  other  species  of  achorion  in  animals 
— mice,  cats,  dogs  and  poultry  (achorion  Quinckeanum,  gallinum, 
gypsceum,  oospora  canina);  but  these  have  been  very  rarely  met 
with  in  men,  in  trichophytoid  eruptions,  sometimes  with  minute 
cups,  but  never  on  the  hairy  scalp. 

Etiology.  Favus  is  contagious,  although  to  a  less  degree  than 
trichophytosis  and  is  rarely  epidemic.  It  is  hardly  ever  contracted 
otherwise  than  in  the  course  of  childhood,  from  five  to  fourteen 
years,  at  school  or  at  home;  it  frequently  happens  that  of  several 
children  who  live  together  only  one  or  two  are  attacked.  As  favus 
has  practically  no  tendency  to  a  spontaneous  cure,  it  may  persist 
throughout  life  and  become  perpetuated  in  certain  families  and 
localities. 

Transmission  from  one  human  being  to  another  is  the  rule  and 
may  be  direct  or  through  the  medium  of  clothes,  head-coverings  or 
toilet  articles.  Favus  of  animal  origin,  as  stated  above,  is  extremely 
rare. 

Favoring  conditions  are  dirt,  poverty  and  promiscuity.  In  Paris, 
cases  of  favus  are  almost  without  exception  imported  from  the 
country  or  from  abroad.  The  disease  tends  to  diminish  in  France; 
it  is  still  most  frequently  met  in  Lyons,  in  the  northwest  and  in  the 
south.  Favus  is  rare  in  England  and  America,  but  common  in 
Poland,  Italy,  Holland  and  Algeria. 

Clinical  Forms. — Tinea  favosa  (XX)  and  onychomycosis  favosa 
(XXI)  have  already  been  described.  I  have  also  pointed  out  the 
characteristics  of  the  alopecia  and  cicatrices  due  to  favus  (XVII). 

Favus  of  the  glabrous  skin  is  not  very  rare,  but  is  found  especially 
in  persons  whose  scalp  has  first  been  infected,  so  that  it  is  generally 
the  result  of  auto-inoculations.  The  face,  the  shoulders,  the  ab- 
domen, the  buttocks  and  the  external  aspect  of  the  limbs  may  be 
attacked.  No  positive  case  of  favus  of  the  mucous  membranes  is 
known;  the   observation   of   Kaposi   and    Kundrat,   concerning   a 


EPIDERMOMYCOSEX 


519 


favus  patient  who  died  with  gastro-intestinal  ulcerations,  is  open  to 
question. 

There  are  two  varieties  of  favus  of  the  hairless  regions  (Fig.  160) ; 
the  circinate  epidermic  variety  (favus  herpeticus)  closely  resembles 
circinate  trichophytic  herpes,  although  it  assumes  a  less  regularly 
circular  form;  the  epidermis  of  the  red  and  scaly  spots  contains  an 
abundance  of  short  mycelial  threads,  spores  and  irregular  tubules; 
the  cupped  variety  develops  as  such  from  the  start,  or  more  often 
originates  from  the  preceding  form  with  the  appearance  of  follicular 
yellow  disks  which  grow  at  a  rapid  rate. 


Fig.  160. — Favus  of  the  hairless  skin;  the  epigastrium  of  this  young  girl  presents 
two  spots,  one  of  which  bears  four  cups,  the  other  being  of  the  variety  known  as  favus 
herpeticus. 


Treatment. — Favus  of  the  body  is  much  more  easily  curable  than 
favus  of  the  hairy  regions.  It  suffices  to  soften  the  cups  with  moist 
dressings,  to  remove  them  by  scraping  with  the  curette  and  to  make 
two  or  three  applications  of  tincture  of  iodin.  As  a  rule,  there  remain 
no  cicatrices,  but  only  simple  macules.  Recurrences  must  be 
guarded  against  by  carefully  watching  the  patient.  [The  treatment 
of  favus  of  the  scalp  has  been  discussed  in  chapter  XX.] 

Trichophytosis. — In  a  series  of  remarkable  contributions,  pub- 
lished from  1841  to  1845,  Gruby  established  the  parasitic  character 
of  the  tineas.  Credit  is  due  to  Bazin  for  the  universal  recognition 
of  this  fact.  During  fifty  years  one  of  these  parasites,  named  the 
trichophyton  tonsurans,  by  Malmsten,  was  assumed  to  be  the  sole 


20 


PARASITIC   DERMATOSES 


cause  of  tinea  tonsurans  of  children,  sycosis  parasitaria  of  men, 
herpes  circinatus  trichophyticus  and  onychomycosis. 

This  view  was  altogether  changed  b\  the  admirable  investi- 
gations of  Sabouraud,  who  confirmed  the  descriptions  of  Gruby, 
but  applied  bacteriological  methods  to  the  study  of  the  tinea-.  He 
recognized  the  fad  confirmed  after  him  b\  Mibelli,  Bodin,  ( '.  Fox, 
yi  ^Jorris,  etc.  thai  the  pathogenic  trichophytons  of  men  and  of 
animals  do  not  belong  to  one  and  the  same  species,  but  constitute 
a  family  of  numerous  genera,  varying  in  their  morphology,  their 
cultural  features,  their  habitat  and  the  clinical  lesions  they  give 
rise  to. 


fticus  circi 

iti). 


Moreover,  one  of  the  parasites  described  b\  Gruby  in  porngo 
decalvans  is  not  botanically  a  trichophyton;  it  is  called  micro- 
sporon  and  the  tinea  produced  b\  it  bears  the  name  of  tinea  tonsurans 
with  small  spores  [microsporia]  of  Gruby-Sabouraud.  It  will  be  dis- 
cussed further  on. 

Trichophytons.  The  true  trichophytons  belong  to  the  genus 
botrytis,  family  mucedinea?. 

I,,'  their  epidermic  products,  the  trichophytons  assume  the  shape 
of  mvcelium  threads  and  -pore-.  The  mycelium  is  made  up  of 
elongated,  slightlv  undulating,  regular,  colorless  and  transparent, 


EPIDERMOM  YCOSES  52 1 

partitioned  and  branching  tubules  (Fig.  161);  the  partitions  are 
usually  very  close  together.  In  each  compartment  a  rounded, 
oval  or  cubical  spore  is  formed;  these  spores  often  remain  in  rows 
or  strands. 

For  the  microscopic  examination  of  scales,  hairs  or  nail  clippings, 
it  suffices  to  place  these  on  a  slide,  add  a  drop  of  40  per  cent,  potash 
solution,  cover  with  a  slip  and  heat  gently  over  a  flame  to  a  tem- 
perature near  the  boiling-point.  Formic  acid  also  clears  up  the 
scales  after  a  little  time  without  heat.  Amplification  from  200  to  300 
diameters  is  the  most  convenient.  In  order  to  obtain  stained  and 
lasting  specimens,  the  epidermic  particles  must  be  rendered  free 
from  fat  with  alcohol  and  ether,  stained  with  Sahli's  blue  and 
mounted  in  Canada  balsam. 

Trichophyton  cultures  are  obtained  without  difficulty  on  agar 
media  containing  1  gram  of  peptone  and  4  grams  of  glycerin  or  sugar 
to  100  grams  of  water.  Barely  visible  particles  of  hairs  or  scales 
should  be  planted  aseptically  and  the  test-tubes  left  without  rubber 
caps  at  laboratory  temperature.  Very  often  the  cultures  are  pure 
from  the  start,  without  its  being  necessary  to  begin  by  first  washing 
the  material  in  alcohol  or  silver  nitrate,  as  recommended  by  some 
authors.  After  the  third  day,  secondary  cultures  can  be  made, 
preferably  on  the  test  medium  of  Sabouraud,  which  gives  the  most 
distinctive  physiognomy  to  the  various  species  and  is  composed  as 
follows:  Granulated  peptone  (Chassaing),  10  parts;  crude  maltose 
(Chanut),  40;  agar-agar,  18;  water,  1000  parts.  A  temperature 
from  75°  to  95°  F.  is  the  most  favorable. 

Besides  the  mycelium,  the  following  organs  of  fructification  of 
the  trichophytons  are  found  in  these  cultures:  Spore-bearing 
hyphens  usually  in  terminal  clusters,  exceptionally  endoconidia  and 
also,  according  to  the  species,  more  or  less  numerous  multilocular 
spindles. 

The  number  of  known  species  of  pathogenic  trichophytons  is 
about  thirty. 

It  has  been  shown  by  the  investigations  of  Plato  (1902),  followed 
by  those  of  Truffi,  that  a  triohophytine  can  be  extracted  from  the 
cultures  of  several  trichophytons,  which  when  injected  into  a  patient 
having  trichophytosis  with  deep  nodes  will  give  rise  to  a  cutaneous 
and  a  general  reaction  not  occurring  in  healthy  persons.  An  extract 
of  achorion  culture,  or  favine,  seems  to  act  even  more  constantly. 
These  injections  or  applications  of  salves  containing  the  toxins, 
might  serve  for  the  treatment  of  the  deep  trichophytoses.  Bruno- 
Bloch  and  Massini  have  confirmed  these  observations  and  have, 
moreover,  succeeded  in  immunizing  animals  against  the  tineas  in 
general,  by  a  preliminary  inoculation  wTith  trichophyton  gypseum 
or  an  animal  achorion.     Investigations  in  this  direction  now  under 


522  PARASITIC  DERMATOSES 

way  promise  important  results  from  the  standpoint  of  diagnosis, 
prophylaxis  and  treatment. 

Clinical  Forms. — The  trichophytons  give  rise  to  various  cutaneous 
affections,  according  to  their  localization  on  the  scalp,  the  hairless 
skin,  the  beard  or  the  nails. 

Tinea  trichophytica  has  been  described  elsewhere  |  XX).  It  maybe 
due  to  several  species.  According  to  Sabouraud,  it  may  be  stated  that 
at  the  present  writing,  of  101)  cases  of  this  affection  in  Paris,  .10  are 
due  to  the  trichophyton  crateriforme,  30  to  the  trichophyton  acumina- 
tum; and  the  20  remaining  eases  are  due  to  various  species  among 
which  the  trichophyton  violaceum  predominates.  In  other  countries, 
these  proportions  would  undoubtedly  be  different. 

The  granuloma  trichophyticum  of  Majocchi  (1883-1906)  is  a  rare 
form  characterized  by  intradermic  nodules,  sometimes  agminated 
or  in  strands,  which  develop  in  the  cutis  of  the  alopecic  and  squam- 
ous spots;  they  consist  of  a  mass  of  inflammatory  cells  and  a  ring 
of  giant  cells  surrounding  fragments  of  trichophytic  hairs.  Pini 
and  Lutati  have  observed  a  few  similar  cases. 

Sycosis  trichophytica  of  the  beard,  kerion  Celsi  and  folliculitis 
agminata  which  have  already  been  described  in  this  book  (XIX),  are 
follicular,  inflammatory  and  even  suppurative  forms  of  trichophy- 
toses of  animal  origin.  Their  most  common  germ  is  the  trochophyton 
gypseum  of  horses;  sometimes  it  is  a  bird  trichophyton  with  rose- 
colored  cultures.  These  parasites  are  ectothrix;  they  possess  pyo- 
genic properties.  Adults  are  more  susceptible  to  the  contagion 
than  children;  it  results  either  from  direct  contact  with  the  tricho- 
phytic animal — horse,  dog,  cow,  birds,  etc.,  whose  lesions  may  not 
always  be  very  evident — or  indirectly  from  the  handling  of  con- 
taminated articles,  brushes,  coverings,  etc.  Transmission  may  then 
take  place  from  man  to  man,  by  intermediation  of  the  barber,  for 
instance.    The  sequence  of  cases  is  often  difficult  to  establish. 

Jadassohn  has  pointed  out  in  children  suffering  from  kerion,  the 
frequent  co-existence  of  not  very  persistent  folliculitides  of  the 
trunk,  supposed  to  be  of  toxemic  character  and  designated  as 
disseminated  lichenoid  trichophytosis.  The  above  statements  on  the 
etiology  of  sycosis  are  likewise  applicable  to  that  of  onychomycosis 
trichophytica. 

Cutaneous  trichophytosis  of  the  hairless-  .shin  was  formerly  known 
under  the  name  of  herpes  drcinatus  which  also  comprised  cutaneous 
microsporia  and  epidermophytosis. 

Cutaneous  trichophytosis  is  observed   in: 

1.  Children  suffering  from  tinea  and  persons  in  their  environment; 
these  cases  are  usually  due  to  one  of  the  ordinary  endothrix  tricho- 
phytons of  the  tineas.  It  is  not  uncommon,  as  was  first  pointed  out 
by  Besnier,  that  the  epidermic  manifestation  which  is  very  evident 
leads  to  the  discovery  of  a  previously  undetected  tinea  tonsurans. 


EPIDERMOM  YCOSES 


523" 


2.  Persons  of  all  ages,  free  from  tinea,  whose  occupation  or  incli- 
nation puts  them  in  frequent  contact  with  animals.  In  these  cases, 
the  parasite  is  presumably  an  ectothrix  of  animal  origin  and  does 
not  invade  the  scalp. 

Any  region  of  the  body  may  be  involved;  the  seat  of  election  of 
cutaneous  trichophytosis,  however,  is  the  exposed  parts,  such  as  the 
face,  neck,  hands  and  forearms.  Its  palmar  and  plantar  localization, 
of  special  appearance,  has  been  mentioned  under  the  heading  of  the 
keratodermas  (p.  216). 

Trichophytosis  of  the  hairless  parts  manifests  itself  in  the  form  of 
erythemato-squamous  spots,  noteworthy  on  account  of  their  strictly 
geometrical  orbicular  circumference  and  their  distinctly  outlined 
clean-cut  borders  (Fig.  162).  This  feature  at  once  attracts  atten- 
tion.   It  is  altogether  exceptional  for  the  disk  to  be  incomplete  or 


Fig.  162. — Spot  of  herpes  circinatus  trichophyticus  on  a  child's  neck. 


the  circle  broken.  When  the  affection  is  lodged  on  the  fingers,  the 
circle  is  continued  from  one  finger  to  the  other,  just  as  at  the  eye  or 
mouth  it  passes  from  one  eyelid  or  one  lip  to  the  other. 

The  spot  is  pink  or  red,  often  with  a  dusky  center,  covered  with 
powdery,  flaky  or  crusted  scales;  it  is  marginate  or  plainly  cir- 
cinate  through  healing  from  the  center. 

Another  valuable  but  inconstant  characteristic  is  the  vesiculation 
noted  at  the  border  of  the  spot;  vesicles  may  be  observed  over  the 
entire  lesion,  or  there  may  be  several  concentric  circles  of  vesicles 
(up  to  7  on  a  cast  in  the  Saint  Louis  Hospital).  Sometimes,  the 
vesicular  contents  are  turbid  or  purulent.  The  vesiculation  is  of  the 
eczematous  type. 

The  floor  of  the  spots  is  sometimes  more  or  less  edematous  or 
infiltrated.  The  downy  hairs  may  be  dull  and  brittle  or  encased  in 
scales  at  their  base.    Itching  is  very  variable  in  its  severity. 


524  PARASITIC   DERMATOSES 

All  these  variations  arc  much  more  dependent  upon  the  kind  of 
trichophyton  involved  than  upon  individual  or  accessory  factors. 

As  a  rule,  all  the  spots  arc  of  the  same  type  in  a  given  case 

The  coiir.se  of  herpes  circinatus  is  almost  always  rapid;  in  a  few 
days,  a  spot  will  reach  the  dimensions  of  a  silver  quarter;  the  exten- 
sion of  the  borders  may  he  more  than  1  nun.  daily  for  some  species. 
Slightly  older  patches  may  reach  the  size  of  the  palm  or  the  entire 
hand.  Very  frequently  these  spots  are  multiple  and  of  different 
ages,  the  most  recent  spots  being  the  result  of  re-inoculations.  It 
was  formerly  taught  that  the  confluence  of  two  or  more  lesions  may 
give  rise  to  polycyclic  spots  or  arabesques  and  that  a  considerable 
portion  of  the  integument  may  become  invaded;  in  all  probability 
many  cases  of  this  kind  belong  to  the  group  of  epidermophytosis. 

The  diagnosis  of  herpes  circinatus  is  often  obvious  at  once 
through  the  clinical  features;  in  doubtful  eases,  it  will  be  con- 
firmed by  the  microscopical  examination  of  the  scales  from  the 
periphery  of  the  lesion.  The  parasite  here  appears  in  the  form  of 
band-like,  slightly  wavy,  fairly  regular,  often  bifurcated  mycelium 
filaments,  composed  of  short  members  (Fig.  161);  even  unstained 
specimens  show  the  very  close  partitions  between  the  square  or 
rectangular  segments,  which  is  not  the  case  in  the  mycelium  of 
epidermic  microsporia. 

( 'onfusion  of  herpes  circinatus  must  be  avoided  with  the  trichoph- 
ytoid  patches  of  common  eczema,  which  are  less  regularly  out- 
lined and  accompanied  by  scattered  eczematous  lesions;  with  the 
eczematides,  whose  configuration  is  less  orbicular  and  whose  course 
is  slower;  with  pityriasis  rosea  of  Gibert,  which  Kaposi  persistently 
classified  under  "herpes  tonsurans  maeulosus,''  but  which  is  dis- 
tinguished by  is  course,  its  ovaloid  patches  and  the  absence  of 
vesiculation;  it  is  only  the  primary  patch  which  may  sometimes 
require  microscopical  examination. 

The  distinctive  features  differentiating  the  cutaneous  trichophy- 
toses from  epidermophytosis  will  be  discussed  presently.  Under 
certain  special  circumstances,  the  question  of  a  differential  diagnosis 
from  various  exotic  epidermomycoses  may  arise. 

Treatment  by  painting  with  pure  tincture  of  iodin,  repeated 
three  times  at  intervals  of  two  days,  or  with  1  diluted  iodin 
tincture  in  daily  applications;  or  with  iodinized  vaselin  1  to 
Mid,  leads  to  a  cure  of  herpes  circinatus  in  from  ten  to  fifteen 
days.  This  medication  has  replaced  the  formerly  classical  employ- 
ment of  turpeth-mineral  sake  I  to  1.")  and  of  naphthol  ointments. 

Epidermophytosis  Inguinalis  (Eczema  Marginatum  of  Hebra). — 
The  cutaneous  affection  described  by  Pr.  Hebra,  under  the  name  of 
eczema  marginatum  was  recognized  as  of  mycotic  origin  by  Ivobner, 
Pick  and   Kaposi,  but  continued   to  be  confused  with  the  cutaneous 


E  I' IDE  HMO  M  YCOSES  525 

trichophytoses.  The  accurate  investigations  of  Sabouraud  (1908) 
have  demonstrated  that  it  is  always  due  to  the  same  parasite,  the 
cpidermophyton  inguinale;  although  very  closely  related  to  the 
trichophytons,  it  differs  from  these  botanically  and  through  the 
fact  of  its  never  invading  the  hairs. 

The  eczema  marginatum  of  Hebra  has  its  seat  of  predilection  at 
the  inner  aspect  of  the  root  of  the  thighs.  It  begins  in  this  region 
on  one  or  both  sides,  as  one  or  several  nummular  spots  of  a  bright  red 
color,  sharply  outlined  and  pruritic;  by  their  rapid  growth,  these 
spots  become  confluent  in  circinate  patches,  with  red  circinate 
borders,  often  finely  vesicular  or  bordered  by  white  lamellar  scales. 
Meanwhile,  the  center  usually  fades  or  remains  pigmented,  inter- 
spersed with  scanty  scales  and  excoriations,  or  with  small  crusts 
due  to  scratching.  Around  the  principal  patch,  secondary  patches 
often  originate  on  the  thighs,  as  far  down  as  the  knees,  on  the  pubis 
or  the  buttocks,  taking  the  same  course  and  sometimes  involving 
very  extensive  surfaces.  On  the  scrotum  and  penis  the  lesions  are 
less  distinct,  almost  obliterated.  The  eruption  may  spread  to  the 
axillae,  the  submammary  folds,  the  legs  and  feet;  not  infrequently 
it  coincides  with  epidermophytosis  of  the  extremities;  unless 
properly  treated,  it  may  last  for  months  and  years. 

Not  uncommonly,  especially  in  men  and  more  particularly  in  the 
well-to-do  classes,  eczema  marginatum  is  contagious  through  sexual 
intercourse  and  also  indirectly  through  water-closets  or  underwear; 
as  a  matter  of  fact,  small  epidemics  are  observed  in  colleges,  work- 
shops, asylums,  etc.  [The  "jock-strap,"  the  hired  bathing  suit, 
etc.,  are  common  sources  of  infection.] 

Microscopical  examination  of  the  scales — which  must  always  be 
taken  from  the  red  border — shows  an  abundance  of  mycelium 
composed  of  quadrangular  or  sometimes  ovoid  elements,  resembling 
that  seen  in  Fig.  161.  Cultures  grown  on  test  media  are  radiating, 
powdery,  of  a  lemon  yellow  color,  or  downy  through  pleo- 
morphism. 

Eczema  vulgare  is  distinguished  from  epidermophytosis  by  its 
frayed  margins  and  its  less  restricted  localization ;  intertrigo,  by  its 
symmetry  and  its  diffuse  margins;  erythrasma,  by  its  relatively 
stationary  behavior,  its  dry  finely  scaly  surface,  of  a  uniform  dusky 
pink  color,  without  vesiculation  of  the  margins;  the  mycelium  of  the 
microsporon  minutissimum  is  infinitely  more  slender  than  that  of 
the  epidermophyton  (compare  Fig.  161  and  Fig.  166). 

Epidermophytosis  is  differentiated  from  herpes  circinatus  tricho- 
phyticus  by  its  predilection  for  the  covered  regions,  by  its  tendency 
to  become  confluent  in  polycyclic  surfaces  or  in  arabesques;  the 
patches  are  not  invariably  disks  or  closed  circles,  but  are  sometimes 
open  on  one  side.    The  demonstration  of  the  invasion  of  the  downy 


526  PARASITIC  DERMATOSES 

hairs,  or  cultures  of  the  parasite,  may  he  required  in  support  of  the 
diagnosis,  but  the  matter  is  of  no  particular  importance. 

Treatment  by  painting  daily  with  iodin  tincture  diluted  with  three 
or  four  parts  of  80  per  cent,  alcohol,  is  usually  sufficient;  if  neces- 
sary, it  may  be  supplemented  by  the  employment  of  a  zinc  salve 
with  oil  of  cade  (5%)  and  salicylic  acid  (1%).  [Whitfield's  oint- 
ment, Ac.  Salicyl.  1.0,  Ac.  Benzoic.  2.0,  Petrolati,  15.0  is  most 
valuable.]  Chrysarobin  ointments  are  also  very  effective,  but 
involve  the  risk  of  a  severe  and  painful  dermatitis. 

Epidermophytosis  of  the  Extremities. — The  same  epidermophy- 
ton  inguinale — as  discovered  by  Sabouraud  in  1910 — is  the  patho- 
genic agent  of  a  very  common  affection  of  the  interdigital  spaces  of 
the  feet,  which  was  formerly  confused  with  eczema,  dysidrosis, 
intertrigo,  or  maceration  due  to  hyperidrosis  of  this  region. 

The  lesions  chiefly  occupy  the  floor  of  the  interdigital  folds, 
especially  between  the  fourth  and  fifth  toe  and  the  flexion  folds  of 
the  toes.  A  macerated  horny  layer  is  present  and  becomes  detached 
in  the  form  of  white  shreds,  leaving  a  bright  red  surface  or  a  cheesy 
material;  in  the  circumference  a  few  vesicles  are  sometimes  seen, 
which  may  dry  or  coalesce  into  an  eczematiform  surface.  This  dry, 
vesicular  or  impetiginous  parasitic  eczema  may  extend  to  the  dorsal 
aspect  of  the  foot  as  well  as  to  the  sole,  even  encroaching  upon  the 
plantar  arch  as  far  as  the  heel.  With  remissions  and  exacerbations 
the  disease  may  be  prolonged  for  many  years  or  indefinitely. 
Through  the  itching  induced  by  it,  the  burning  sensations  and 
superadded  pyodermatitis,  it  becomes  a  source  of  distress,  interferes 
with  the  wearing  of  shoes  and  may  make  prolonged  walking  impos- 
sible. Failure  to  recognize  this  dermatosis  has  often  caused  the 
patients  to  be  subjected  to  strict  diets,  cures  in  watering-places,  etc. 

On  the  hands  and  fingers,  epidermophytosis  is  likewise  met  with, 
although  much  less  frequently,  in  the  form  of  vesicular  lesions  or 
squamous,  rarely  circular  exfoliations  of  the  palmar  surfaces;  it  is 
almost  invariably  confused  with  a  dysidrosis. 

Epidermophytosis  of  the  extremities  is  accordingly  eczematiform 
or  dysidrotiform  rather  than  like  the  palmar  and  plantar  trichophy- 
tosis. Microscopic  examination  is  necessary  to  establish  a  positive 
diagnosis;  the  mycelium  is  abundantly  present  in  the  scales.  Cul- 
tures arc  difficult  on  account  of  bacterial  contaminations. 

Treatment. — The  treatment  is  the  same  as  that  of  inguinal  mar- 
ginate  eczema,  but  in  view  of  the  thickness  of  the  horny  layer,  the 
action  of  the  dilute  iodin  tincture  must  be  reinforced  by  moist 
dressings  during  the  night,  followed  by  careful  scraping  and  cleans- 
ing. Sabouraud  recommends  an  ointment  of  lard  and  chrysarobin 
(1  to  3  to  100)  with  salicylic  acid  (5  to  100),  avoiding  all  washing 
with  soap  and  water.  [In  my  experience,  a  five-day  course  of 
i)reuw's  ointment  is  incomparably  the  most  effective  treatment.] 


EPIDERMOMYCOSES  527 

Microsporia. — The  parasite  of  tinea  tonsurans  with  small  spores, 
the  microsporon  (p.  421),  was  discovered  by  Gruby,  then  misinter- 
preted, lost,  and  re-discovered  by  Sabouraud  in  1892.  It  differs 
from  the  trichophytons  in  its  microscopical  and  botanical  features 
and  in  the  appearance  of  the  lesions  produced  by  it.  The  contri- 
butions of  Adamson,  C.  Fox  and  Blaxall,  Bodin,  etc.,  and  especially 
the  work  of  Sabouraud,  collected  in  his  book  on  The  Tineas,  1910, 
have  definitely  settled  the  scientific  data  concerning  it. 

The  microsporon  Aiidouini — the  first  discovered,  which  infests 
especially  Northeastern  Europe,  is  at  the  present  time  endemic  in 
England,  causes  two-thirds  of  the  cases  of  microsporic  tinea  ton- 
surans in  Paris  and  is  responsible  for  the  epidemics  in  children's 
asylums  and  schools — is  now  known  to  be  not  the  only  species  met 
with  in  man. 

There  are  about  ten  other  microsporons  which  are  for  the  most 
part  of  direct  or  indirect  animal  origin  (m.  lanosum  or  caninum,  m. 
felinum,  m.  equinum)  and  give  rise  in  nearly  all  countries  of  the 
earth  to  sporadic  cases  or  small  family  epidemics. 

The  microscopical  demonstration  and  the  culture  of  micro- 
sporons are  the  same  as  those  of  the  trichophytons.  Cultures  of 
the  microsporon  Audouini,  on  the  maltose  medium  of  Sabouraud 
and  at  room  temperature,  become  visible  on  the  fifth  day,  measure 
5  cm.  at  the  end  of  a  month  and  resemble  a  layer  of  white  or  grayish 
short-nap  wool.  Cultures  of  microsporons  of  animal  origin  are  of 
quicker  growth  and  more  downy,  their  fluff  showing  abundant 
multilocular  spindles  under  the  microscope;  furthermore,  the  last- 
named  cultures  undergo  from  the  fifth  week  on  a  downy  pleomorphic 
degeneration,  not  shown  by  cultures  of  the  microsporon  Audouini. 

Microscopical  examination  of  microsporon  cultures  shows  modes 
of  reproduction  akin  to  but  different  from  those  of  achorions  and 
trichophytons,  in  the  form  of  pyriform  swellings  on  the  filaments, 
large  spindle-shaped  and  partitioned  conidia,  pectinate  hyphens, 
clusters  of  cylindrical  and  sessile  conidia,  etc. 

The  microsporon  Audouini  affects  exclusively  the  scalp  of  chil- 
dren, where  it  causes  the  microsporic  tinea  which  has  been  described 
elsewhere  in  the  work  (XX). 

It  very  rarely  vegetates  on  the  hairless  skin,  where  it  produces 
scaly  pinkish  spots  of  ephemeral  character  and  self-limited  duration. 

Animal  microsporons  outside  of  the  hairy  scalp  and  even  in  adults 
sometimes  cause  erythemato-squamous,  nummular  or  circinate, 
pink  or  dun-colored  spots,  in  large  numbers,  exceptionally  even 
generalized  over  the  entire  body.  These  spots  of  cutaneous  micro- 
sporosis  may  last  a  month  and  a  half.  A  few  cases  of  microsporic 
sycosis  of  the  beard  have  been  observed  in  men. 

In  the  scales  of  tinea  tonsurans  with  small  spores,  or  in  those  of 


528  PA  RA  81  TIC  DERMA  TOSES 

epidermic  microsporosis,  examination  in  potash  solution  shows 
abundant  twisted  and  serpentine  filaments,  with  apparently  few 
partitions,  frequently  bearing  small  lateral  protuberances.  After 
staining,  this  mycelium  appears  divided  into  septa  at  short  intervals. 

Tropical  Epidermomycoses.  Tokelau  or  Tinea  Imbricata. — This 
dermatosis  is  endemic  in  the  islands  of  the  Pacific  and  in  Indo-(  'hina. 
It  is  observed  in  natives  of  all  ages. 

The  disease,  which  persists  throughout  life,  manifests  itself  as 
regular  erythemato-squamons  concentric  circles.  The  shell-like 
scales  are  adherent  at  their  peripheral  portion,  loose  at  their  central 
portion  and  overlap  like  the  tiles  of  a  roof.  The  circles  and  their 
underlying  patches  increase  in  number  and  size,  become  interrupted 
through  a  variety  of  factors,  until  the  entire  integument  becomes 
covered  with  squamous  arabesques,  including  the  face,  the  extremi- 
ties and  the  nails,  but  not  including  the  scalp.  The  patient  roughly 
resembles  a  case  of  ichthyosis;  he  suffers  from  severe  and  continuous 
pruritus. 

The  microscope  shows  a  dense  network  of  branching  and  spore- 
bearing  mycelium  in  the  scales;  the  condition  is  referred  by  Manson 
to  a  trichophyton  capable  of  inoculation  from  man  to  man  but 
not  growing  in  cultures,  namely  the  trichophyton  concentricum  of 
Blanchard;  Tribondeau  describes  the  organism  as  aspergillus 
lapidophyton.  Castellani  reports  successful  cultures  and  inoculations 
of  endodermophytons. 

Carates  and  Central  A  merican  Epidermomycoses. — Under  the  name 
of  carates,  mat  del  Pinto,  or  Pinta,  are  designated  numerous  epidermo- 
mycoses due  to  chromogenic  parasites,  widely  distributed  in  tropical 
America  and  although  known  for  a  long  time,  as  yet  inadequately 
studied.  They  are  characterized  by  spots  which  become  confluent 
in  large  desquamating  lobulated  patches  and  may  become  general- 
ized. There  exists  a  black,  blue,  violet,  red,  yellow  and  a  white 
variety;  all,  except  the  red  one,  may  ultimately  turn  white.  The 
odor  is  offensive,  the  hairs  fall  out,  the  nails  remain  intact.  Asso- 
ciation with  scabies  is  common.  The  scales  enclose  a  profuse  tangle 
of  mycelium.  The  chromogenic  parasites,  studied  by  Montoya, 
belong  to  the  groups  of  aspergillus,  penicilium,  monilia,  montoyella, 
microsporon  and  trichophyton. 

Aside  from  these  carates,  various  imperfectly  known  epidermo- 
mycoses are  met  with  in  Central  America,  which  give  rise  to  red 
patches  covered  with  white  scales,  sometimes  hyperkeratotic,  with 
polycylic  contours;  they  may  attack  the  nails  and  are  of  indefinite 
duration.  In  a  case  (Fig.  163)  observed  by  me  in  a  patient  from 
Ecuador,  published  in  1903,  the  scales  enclosed  a  network  of  a 
mycelium  which  Bodin  (of  Rennes)  successfully  grew  in  cultures; 
he  found  it  to  be  related  to  trichophytons  and  still  more  closely  to 


EPIDERMOM  YCOSES 


529 


the  lophophyton  gallinse,  the  parasite  of  chicken-favus,  which 
causes  the  "white  comb"  in  fowls.  There  are  probably  more  or  less 
analogous  epidermophytoses  due  to  various  fungi  in  many  tropical 
countries. 

The  treatment  of  these  exotic  mycoses  is  extremely  tedious.  I 
have  obtained  the  best  results  with  chrysarobin  in  ointments  (of  1 
to  3  per  cent.),  or  in  varnishes  like  traumaticine. 


Fig.  163. — -Central  American  epidermomycosis  of  seven  years'  standing,  diagnosed 
as  carate;  note  the  lesions  of  the  nails  and  genital  organs.  The  patient  suffered  at  the 
same  time  from  scabies. 


Pityriasis  Versicolor. — Pityriasis  versicolor  is  a  parasitic  affection 
of  the  epidermis,  characterized  by  yellowish  and  scaly  spots,  caused 
by  the  microsporon  furfur  or  malassezia  furfur. 

Confused  by  the  ancients  with  pigmentary  spots,  pityriasis 
versicolor  was  distinguished  from  these  by  Willan,  who  classified 
it  among  the  squamous  diseases  and  gave  it  the  name  it  bears. 
Eichstedt,  in  1846,  discovered  the  parasite,  which  was  christened  by 
Ch.  Robin. 

Pityriasis  versicolor  manifests  itself  as  sharply  defined  patches, 
varying  in  color  from  a  dirty  yellow,  tan  or  chamois  to  a  dark  brown, 
sometimes  with  an  admixture  of  a  pinkish  shade.  The  color  varies 
in  different  persons,  different  regions,  and  even  on  the  same  spot  at 
different  times;  hence  the  name  of  versicolor.  In  the  colored  races, 
the  spots  are  lighter  than  the  normal  skin  and  achromic  by  contrast. 

The  spots  are  slightly  scaly,  powdery  or  entirely  smooth.  Their 
34 


530  PARASITIC  DERMATOSES 

essential  feature,  however,  is  that  the  horny  epidermis  is  here  less 
adherent  than  under  normal  conditions,  so  that  on  vigorous  scratch- 
ing with  the  nail  a  desquamated  shred  becomes  detached  without 
bleeding.  This  "nail-scratch  or  flake  sign"  is  almost  pathognomonic 
and  is  due  to  the  fact  that  the  presence  of  the  parasite  permits  the 
superficial  horny  layers  to  slide  over  the  deeper  layers. 

The  spots  are  not  prominent.  Their  shape  and  dimensions  are 
extremely  variable.  They  may  be  punctate,  guttate,  in  disks, 
rings  or  patches,  or  cover  large  surfaces  with  geographical  contours, 
sometimes  involving  a  large  portion  of  the  thorax;  these  various 
configurations  are  often  seen  on  the  same  individual. 

Any  region  of  the  integument  may  be  the  seat  of  pityriasis  versi- 
color, with  the  exception  of  the  hands  and  feet.  Its  seat  of  election 
is  the  upper  part  of  the  chest,  in  front  and  behind,  whence  it  reaches 
the  shoulders,  the  flanks,  the  abdomen,  the  groins,  the  arms  and 
rarely  the  legs.  It  is  exceptionally  observed  on  the  neck,  the  chin 
and  even  on  a  large  portion  of  the  face. 

The  growth  of  the  vegetating  parasite  as  a  rule  causes  no  itching 
at  all,  so  that  the  patients  are  not  aware  that  they  are  affected  with 
a  parasitic  dermatosis.  The  duration  of  the  disease  is  always  very 
protracted  and  indefinite;  it  may,  however,  heal  spontaneously, 
for  it  is  never  met  with  in  the  aged.  It  progresses  and  becomes 
aggravated  under  the  influence  of  sweating  and  in  the  absence  of 
ablutions  and  remains  stationary  under  contrary  conditions. 

Microsporon  furfur  grows  exclusively  in  the  horny  layer  and  pro- 
duces no  inflammatory  reaction.  It  never  invades  the  hairs.  In 
the  shreds  detached  with  the  finger-nail  may  be  seen  (after  clearing 
with  potash  and  under  a  magnification  of  300  diameters)  numerous 
clusters  of  fifteen  to  thirty  round  spores,  with  double  contours, 
measuring  from  3  to  5  /*.  From  these  masses,  radiating  and  inter- 
laced mycelium  filaments  which  traverse  the  intermediate  spaces 
are  given  off.  They  are  winding,  short,  somewhat  irregular,  slightly 
branching,  divided  by  septa  and  in  places  spore-bearing  (Fig.  164). 

The  culture  of  microsporon  furfur,  remarkably  enough,  meets 
with  great  difficulties;  successful  cultures  were  grown  by  Mat- 
zenauer  and  Nicolle,  the  latter  using  glycerin-agar. 

The  etiology  naturally  depends  upon  the  transmission  of  the 
parasite.  But  pityriasis  versicolor  is  very  slightly  contagious;  it 
is  rare  for  husband  and  wife  to  infect  each  other  or  to  convey  the 
contagion  to  their  children.  Kobner  after  many  attempts  succeeded 
in  inoculating  himself  and  in  infecting  rabbits.  The  incubation 
lasts  over  a  month. 

This  epidermomycosis  is  common  among  adolescents  and  adults 
of  both  sexes;  it  is  very  rarely  seen  at  an  early  age.  In  all  prob- 
ability it  requires  special  regional  conditions.    The  influence  of  a 


EPIDERMOM  YCOSES 


531 


tuberculous  soil  has  been  exaggerated;  for  some  time,  a  relation 
between  the  microsporon  and  the  agent  of  tuberculosis  was  erro- 
neously surmised.  The  frequent  coincidence  is  probably  accounted 
for  by  the  sweating  of  consumptives,  the  habitual  wearing  of 
flannels  and  the  fear  of  bathing. 

The  diagnosis  is  based  essentially  upon  the  "flake  sign;"  a 
microscopical  examination  is  almost  superfluous.  If  only  the  phy- 
sician will  think  of  looking  for  this  sign,  a  confusion  with  congenital 
pigmentary  spots,  chloasma,  pigmentary  syphilides,  eczematides, 
etc.,  is  impossible.  The  distribution  of  certain  pigmentary  spots  of 
leprosy  may  be  analogous  to  that  of  pityriasis  versicolor. 


Fig.   164. — Microsporon  furfur  in  a  scale  from  pityriasis  versicolor;  stained  with 
Sahli's  blue.      X  325. 


Although  common  pityriasis  versicolor  may  occur,  as  I  have 
myself  seen,  among  the  inhabitants  of  Annam  and  Cambodia, 
there  is  in  addition  a  tropical  pityriasis  versicolor,  or  tinea  flava,  or 
parasitic  achromia  with  estival  exacerbations  (Jeanselme).  This 
epidermomycosis  is  very  common  in  the  far  Orient  and  is  character- 
ized by  yellowish,  slightly  scaling  spots  which  preferably  occupy 
the  face,  neck  and  upper  trunk,  is  of  very  slow  development  and 
difficult  to  cure.  It  is  caused  by  malassezia  tropica  (Castellani,  1905) 
which  has  a  short,  swollen  or  club-shaped  mycelium  with  spores 
not  always  arranged  in  clusters. 

The  treatment  of  pityriasis  versicolor  must  aim  at  removing 
the  horny  layer  which  alone  harbors  the  parasite.  Not  a  spore 
must  be  left  behind,  so  as  to  guard  against  recurrence;  on  the 
other  hand,  unnecessary  irritation  must  be  avoided.  Tincture  of 
iodin,  employed  as  in  herpes  circinatus,  lard  with  chrysarobin 
(1  to  1000),  or  simply  soft-soap  rubbed  on  for  ten  minutes  followed 


532 


PARASITIC   DERMATOSES 


by  a  bath,  arc  usually  sufficient.  For  regions  where  the  skin  is 
sensitive,  in  the  groins  or  in  the  axillae,  recourse  may  be  had  to 
naphthol  (1  to  30)  or  sulphur  (1  to  20)  salves  and  to  salicylic  acid 
ointments  (1  to  30),  not  forgetting  washes  with  soap  and  baths,  as 
well  as  disinfection  of  the  body  linen.  [A  simple  and  effective  treat- 
ment consists  in  a  daily  bath  with  soap  followed  by  a  sponging  with 
a  1  to  8  solution  of  photographers'  Hypo  for  a  week;  the  course  of 
treatment,  whatever  it  may  he,  should  he  repeated  after  two  weeks' 
interval.] 

Erythrasma.  The  practitioner  is  usually  not  so  well  acquainted 
with  this  disease,  although  it  is  as  common  as  pityriasis  versicolor; 
it  is  an  epidermomycosis  due  to  the  microsporon  minutissimum  and 
appears  in  the  form  of  brownish  or  yellowish-pink  patches  especially 
in  the  inguinal  folds. 


Fig.  165.— Erythrasma 
.somewhat  more  extensive 
i  um  of  Hebra.  The  micrc 
iMUT  (,!'  microsporon  miimt 


The  territory  occupied  by  the  epidermomycosis  was 
um  usual  in  this  case,  which  resembles  eczema  margina- 
lope  showed  the  abscess  of  epidermophyton  and  the  pres- 


Erythrasma  is  found  in  adult  or  old  men,  of  all  social  classes,  much 
more  rarely  in  women  and  never  in  children. 

Its  origin  always  escapes  attention;  the  patients  are  usually 
unaware  of  having  it  and  are  ignorant  of  its  onset.  Subjective 
symptoms  are  absent;  sometimes  moderate  itching  is  noted  after 
sweating.    The  course  is  very  slow;  the  duration  is  indefinite. 

The  seat  of  election  of  this  dermatosis  is  in  the  genitocrural  fold 
high  up  on  the  internal  aspect  of  the  thigh  (Fig.  165);  it  rarely 
encroaches  upon  the  pubis  and  the  scrotum.  The  lesions  are  uni- 
lateral or  bilateral.    Much  more  rarely  the  axillae  are  also  involved. 

The  erythrasma  patch,  ordinarily  from  5  to  12  cm.  wide  in  all 
diameters  has  an  always  distinct,  polyeyclic  and  serrated  circum- 


EPIDERMOMYCOSES  533 

ference;  outside  of  the  principal  patch,  small  islands  of  the  same 
character  may  be  found  on  the  thighs,  the  abdomen  and  elsewhere, 
but  this  is  altogether  exceptional.  The  color  is  uniform  as  a  rule 
but  very  variable  according  to  the  moment  when  seen,  dark  red, 
deep  yellow,  brownish  with  a  tinge  of  pink.  The  surface  is  level, 
powdery,  finely  squamous,  and  often  criss-crossed  in  very  fine  folds. 
It  is  oily  and  moist  during  perspiration. 

Examination  of  the  scales  under  the  microscope,  with  a  magnifi- 
cation of  400  diameters,  after  treatment  with  potash  solution, 
serves  to  demonstrate  the  parasite  in  some  cases,  but  not  easily. 
It  is  better,  after  removing  the  fat  with  ether,  to  stain  the  scales 
with  Sahli's  blue  or  with  phenol-thionine  (Fig.  166). 


Fig.  166. — Microspores  minutissimum  in  a  scale  of  erythrasma.     Stained  with 
Sahli's  blue.      X  1000. 


This  parasite  is  the  microsporon  minutissimum,  or  discomyces 
minutissimus ,  discovered  by  Burchardt  in  1859.  It  appears  in  the 
form  of  very  fine  filaments,  less  than  1  n  wide,  twisted  and  branching, 
apparently  fragmented  and  provided  with  spores  at  their  extremi- 
ties. These  filaments  are  extremely  abundant  and  constitute  a  real 
network  between  the  horny  cells.  Culture  of  the  discomyces  is 
difficult;  but  Michele,  Ducrey  and  Reale  seem  to  have  obtained  it 
and  were  able  to  inoculate  it  on  man. 

Erythrasma  is  very  slightly  contagious;  it  is  rare  for  husband  and 
wife  to  be  simultaneously  affected. 

Transmission  possibly  takes  places  through  underwear,  water- 
closets,  etc. 


534  PARASITIC  DERMATOSES 

The  diagnosis  is  obvious  in  the  majority  of  the  cases,  although 
sometimes  difficult. 

Intertrigo  is  more  inflammatory  and  has  no  sharply  defined 
contours.  Eczematides  are  rarely  so  narrowly  localized.  Partial 
prurigo  is  highly  pruritic  and  lichenized.  Inguinal  epidermo- 
phytosis is  of  a  bright  red  color,  is  polycyclical  and  marginated,  takes 
a  rapid  course  and  has  a  much  larger  parasite. 

The  treatment  is  analogous  with  that  of  pityriasis  versicolor 
and  inguinal  epidermophytosis,  but  erythrasma  is  more  rebellious. 
In  a  few  weeks  an  apparent  cure  is  obtained,  but  great  persever- 
ance is  needed  in  order  to  avoid  a  recurrence.  [The  interrupted 
or  discontinuous  method  of  sterilization  yields  the  best  results 
in  this  as  in  many  other  infectious  diseases.  In  erythrasma  as  in 
pityriasis  versicolor  one  week  of  treatment  should  be  followed  by 
two  weeks  of  rest,  and  several  courses  of  treatment  are  usually 
necessarv.l 


CHAPTER  XXjVI. 
INFECTIOUS  DERMATOSES— PYODERMATITIDES. 

In  the  following  chapters  (XXVI  to  XXIX)  I  shall  discuss  the 
infectious  dermatoses  whose  parasitical  agent  is  established,  known 
and  specific,  or  practically  specific. 

Some  are  referable  to  internal  infections,  such  as  syphilides,  the 
rose-spots  of  typhoid  fever,  of  some  tubercular  eruptions,  etc. 

Others  are  due  to  external  infections,  like  the  pyodermatitides, 
soft  chancre,  some  cutaneous  tuberculoses,  Biskra  boil,  etc. 

The  following  review,  however,  by  no  means  exhausts  the  question 
of  the  part  played  by  infections  in  skin  diseases. 

For  many  eruptions  the  causative  infectious  agent  is  still  unknown 
(example:  eruptive  fevers);  or  it  is  not  specific,  in  the  sense  that 
different  microbic  species  may  lead  to  the  same  syndrome  (examples : 
purpura,  ulcers,  multiple  gangrenes,  elephantiasis) ;  or  it  is  secondary, 
superadded,  perhaps  accessory  (examples:  eczema,  artificial  der- 
matitides,  etc.). 

Finally,  in  many  cases,  the  role  of  an  infectious  agent  is  theo- 
retical, suspected  or  vaguely  surmised  (examples:  polymorphous 
erythema,  secondary  and  primary  infectious  purpuras,  primary 
erythrodermas,  warts,  vegetations,  pemphigus,  acute  nodosities, 
molluscum  contagiosum). 

According  to  the  plan  here  adopted,  these  various  syndromes 
figure  only  in  the  first  part  of  this  work,  which  is  devoted  to  the 
morphology  of  skin  diseases.  In  this  part  only  pathological  entities 
with  an  established  infectious  etiology  are  considered. 

These  infectious  dermatoses,  according  to  the  nature  of  their 
pathogenic  agent,  may  be  classified  as  follows : 

1.  Infectious  dermatoses  caused  by  cocci:  these  are  the  pyo- 
dermatitides, to  be  discussed  first  of  all. 

2.  Dermatoses  caused  by  bacilli,  or  infectious  bacillary  dermatoses 
(XXVII). 

3.  Infectious  dermatoses  caused  by  vegetable  parasites  of  an 
order  higher  than  the  cocci  and  bacilli:  dermatomy coses  (XXVIII). 

4.  Infectious  dermatoses  due  to  protozoa:  spirochetes,  leishmanias, 
etc.  (XXIX).  This  group  comprises  syphilis  and  a  few  more  or  less 
analogous  exotic  dermatoses. 


536        INFECTIOUS  DERMATOSES— PYODERMA  T I  TIDES 


PYODERMATITIDES. 

The  acute  inflammations  of  the  skin  due  to  the  ordinary  microbes 
of  suppuration  or  pyococci  are  called  pyodermatitides. 

Pyococci. — The  vast  majority  of  suppurations  of  the  skin  are 
caused  by  two  groups  of  microbes:  staphylococci  and  streptococci. 
In  each  of  these  groups  numerous  varieties  or  species  are  distin- 
guished which  are  interpreted  by  some  bacteriologists  as  simple 
strains.  These  varieties  differ  from  each  other  in  their  morphology, 
their  cultural  characteristics,  their  habitat  and — what  is  especially 
of  clinical  interest — in  their  virulence. 

Staphylococci  are  cocci  of  somewhat  variable  size,  which  appear 
in  pus  in  the  form  of  diplococci,  or  in  a  series  of  three  or  four  granules; 
in  cultures  they  are  arranged  in  masses  or  clusters. 

They  grow  readily  on  most  of  the  ordinary  artificial  culture  media, 
preferably  at  37°;  they  have  a  variable  chromogenic  capacity  which 
is  the  basis  of  a  differentiation  between  the  cocci  obtained  from  the 
pus,  as  follows:  Staphylococcus  aureus,  Staphylococcus  albus,  Staphy- 
lococcus citreus,  etc.;  they  liquefy  gelatin  more  or  less  rapidly; 
they  possess  a  high  degree  of  vitality. 

Nearly  all  staphylococci  are  pyogenic;  on  inoculation  they  pro- 
duce subcutaneous  abscesses,  peritonitis,  etc.,  in  the  majority  of 
animals.  When  injected  into  the  ear-vein  of  rabbits,  they  give  rise, 
according  to  dosage  and  virulence,  to  a  rapidly  fatal  septicemia, 
miliary  abscesses  of  the  kidneys,  arthritis,  osteomyelitis,  endo- 
carditis, etc.  Garre,  Bockhart  and  Rodet  produced  folliculitis, 
impetigo,  furuncles,  etc.,  by  rubbing  cultures  upon  the  human  skin. 

Up  to  ten  varieties  or  species  of  staphylococci  have  been  described. 
One  of  great  importance  on  account  of  its  abundance  on  the  skin  is 
designated  under  the  names  of  Staphylococcus  cutis  communis,  or 
Coccus  iwlymorphis  of  Cedercreutz.  This  microbe,  which  undoubt- 
edly corresponds  to  the  morococcus  of  Unna,  presents  itself  in  the 
scaly  crusts  of  eczematides  under  the  aspect  of  mulberry-shaped 
clusters;  it  groAvs  on  glycerin-agar  in  porcelain-gray  streaks  or 
drops  and  gives  off  a  butyric  odor.  It  does  not  liquefy  gelatin.  It 
is  usually  considered  as  non-pathogenic,  but  its  inoculation  on  the 
human  skin  has  been  known  to  cause  folliculitis  or  small  vesicles  of 
eczema. 

Staphylococci  are  widely  distributed  in  the  air,  in  dust  and  in 
water;  they  are  regularly  present  in  the  mouth,  at  the  natural 
orifices,  and  are  disseminated  on  the  skin. 

Streptococci  are  cocci  arranged  in  small  chains  of  variable 
length,  often  composed  of  diplococci;  the  size  of  the  granules 
varies.  Streptococci  will  grow  on  all  ordinary  culture  media,  pref- 
erably  under  anaerobic  conditions;   the   optimum   temperature  is 


PYODERMATITIDES  537 

37°.  They  do  not  liquefy  gelatin  and  form  flakes  in  broth-cultures; 
their  vitality  is  readily  destroyed  by  the  air.  In  order  to  isolate  a 
streptococcus  contaminated  with  other  cocci,  Sabouraud  recom- 
mends growing  the  first  culture  in  a  pipette  in  bouillon  or  ascites- 
fluid;  or,  according  to  a  familiar  procedure,  the  suspected  material 
may  be  planted  on  several  slanting  tubes  of  peptone-agar  and 
numerous  streak-cultures  planted  without  recharging  the  platinum 
needle. 

The  virulence  of  different  streptococci  varies  to  an  enormous 
extent.  The  streptococcus  of  erysipelas,  discovered  by  Fehleisen,  the 
Streptococcus  pyogenes  of  Ogston  and  Rosenbach  and  the  strepto- 
coccus of  puerperal  infection,  undoubtedly  belong  to  a  single  species. 
As  regards  other  varieties,  differing  in  their  morphological  and  bio- 
logical features  as  well  as  their  habitat,  the  question  has  not  yet 
been  settled. 

On  inoculation  into  a  rabbit's  ear,  a  very  virulent  streptococcus 
gives  rise  to  fatal  septicemia;  a  less  virulent  germ  causes  erysipelas; 
a  still  weaker  one  will  produce  an  abscess.  By  means  of  intravenous 
injections  into  animals,  practically  all  the  affections  caused  by 
streptococci  in  human  beings  have  been  successfully  reproduced. 

Streptococci  have  their  ordinary  habitat  in  the  air,  in  the  ground, 
on  the  skin  and  especially  in  the  mucous  cavities.  They  are  less 
frequent  on  the  epidermis  than  staphylococci,  but  are  constantly 
present  in  the  mouth  of  healthy  individuals. 

The  relations  existing  between  the  Streptococcus  pyogenes  and  the 
Streptococcus  of  the  saliva  (Veillon),  the  Streptococcus  of  scarlet 
fever,  the  small  granular  streptococcus,  those  which  liquefy  gelatin 
or  are  encapsulated,  etc.,  have  not  been  definitely  established.  Up 
to  46  species  have  been  described  (Gros). 

Other  microorganisms  in  large  number,  but  not  properly  speaking 
pyococci,  are  likewise  more  or  less  commonly  encountered  on  the 
skin  and  in  the  surroundings  of  the  natural  orifices,  such  as :  various 
micrococci;  the  bacillus  of  seborrhea,  epidermidis,  cutis  commune, 
subtilis  fluorescens,  coli,  pseudodiphtheriticus ,  the  bottle-bacillus  or 
Malassez  spores,  etc.;  furthermore,  a  sarcina,  a  leptothrix,  various 
saccharomyces,  etc. 

The  germs  of  the  skin  vary  enormously  in  number  according  to 
circumstances.  The  average  is  assumed  to  be  40,215  per  square 
centimeter;  from  85  millions  to  1212  millions  of  germs  are  left  in  a 
bath,  according  to  Remlinger;  they  flourish  with  especial  luxuriance 
in  the  moist  and  hairy  regions  of  the  body.  Sabouraud  has  shown 
that  they  are  more  abundant  around  pathological  lesions  of  any 
kind.  Their  principal  receptacles  aside  from  the  mucous  orifices 
are  the  follicular  funnels  which  constitute  both  a  shelter  for  the 
germs  and  the  weak  point  in  the  epidermic  armor  (Chapter  XIX). 


538         INFECT  10  US  DERMA  TOSES—P  Y  ODER  MA  TI  TIDES 

It  must  be  understood  that  no  scrubbing  or  ever  so  careful  and 
prolonged  disinfection  can  be  relied  upon  to  remove  or  destroy  all 
the  microbic  inhabitants  of  the  epidermis.  With  special  reference 
to  pyodermatitis,  it  may  be  said  that  the  seeds  are  practically 
ubiquitous.  However,  the  absence  of  cleanliness,  contact  with  con- 
taminated individuals,  with  soiled  clothing  or  other  articles,  will 
naturally  greatly  increase  the  chances  of  infection. 

Pathogenesis. — In  this  respect,  four  points  require  attention:  the 
portal  of  entry,  the  virulence,  the  resistance  of  the  soil  and  the  patho- 
genic mechanism. 

A.  The  portal  of  entry  of  pyogenic  microbes  is  external  in  the 
vast  majority  of  the  cases.  It  is  only  in  the  pyemias,  etc.,  that  they 
reach  the  skin  by  the  vascular  route,  giving  rise  to  intra-  or  sub- 
dermic  abscesses. 

The  protective  barrier  formed  by  the  horny  layer  is  removed 
through  traumatisms  of  all  kinds,  by  parasitis  such  as  sarcoptes  or 
lice  and  by  scratching  in  case  of  pruritus.  It  is  likewise  impaired 
by  maceration  or  chemical  lesions  of  the  epidermis,  such  as  those 
caused  by  poultices,  plasters  and  strong  antiseptics  like  bichloride 
of  mercury,  carbolic  acid,  etc.  It  is  noteworthy  that  the  latter  are 
usually  more  injurious  for  the  epidermis  than  for  the  germs  con- 
tained in  it,  thereby  favoring  the  propagation  of  the  pyodermatitis. 
The  present  tendency  therefore  is  to  replace  the  antiseptic  dressings, 
which  were  so  popular  in  the  past,  by  aseptic  dressings. 

The  reason  why  the  follicular  orifices  so  often  become  the  portal 
of  entry  of  infection  is  that  they  are  usually  already  inhabited  by 
germs  and  on  the  other  hand  are  easily  damaged  by  friction,  move- 
ments, etc.  Preexisting  lesions  of  the  epidermis,  eczematization, 
vesicles  and  bulla3,  offer  a  ready-made  culture-medium  for  the 
pyococci;  secondary  infection,  superadded  suppuration  or  impetigi- 
nization  is  therefore  extremely  common. 

It  is  often  difficult  to  estimate  the  relative  significance  of  the 
primary  cause  and  of  the  secondary  infection,  as  a  matter  of  fact, 
various  chemical  substances  and  certain  specific  microbes  may  be 
pyogenic  in  themselves. 

B.  The  degree  of  virulence  of  the  parasites,  pyococci  and  others, 
is  extremely  variable,  not  only  according  to  the  species  or  strain,  but 
in  the  same  strain.  Some  behave  like  simple  saprophytes;  others 
again  are  highly  pathogenic.  The  virulence  of  a  microbe  may  be 
attenuated  or  exalted  by  different  laboratory  procedures.  Clinically, 
it  is  governed  by  conditions  not  all  of  which  have  been  established; 
the  best  known  although  not  the  only  cause  of  increased  virulence  is 
primary  growth  in  a  pathogenic  focus,  the  effect  being  comparable 
to  the  well-known  increased  virulence  by  passage  through  an 
animal;  it  accounts   for  the  auto-inoculations,  the  contagiousness 


PLATE    II 


BOCKHARDT'S     IMPETIGO  (X  10) 


MPETIGO  OF  TILBURY  FOX  (X  12) 


Schematic   Comparison  of  the  Pyodermatitid.es. 

Pus  and  necrotic  tissues  are  shown  in  yellow ;  the  dots  indicate 
approximately  the  relative  abundance  of  polynuclears  in  the  epidermis 
and  in  the  cutis.  The  amplification  is  stated  with  the  name  of  each 
variety. 


PYODERMATITIDES  539 

and  persistence  of  some  pyodermic  lesions.  A  very  considerable 
number  of  common  microorganisms  are  actually  under  suspicion, 
being  capable  of  assuming  pathogenic  properties  under  a  variety  of 
circumstances. 

C.  The  resistance  of  the  soil  against  pyococci  is  also  extremely 
variable.  Although  immunity  against  them,  either  temporary  or 
permanent,  does  not  exist,  the  susceptibility  is  evidently  increased 
under  certain  conditions.  In  children  and  youthful  individuals, 
such  conditions  are  represented  by  the  so-called  lymphatic  consti- 
tution or  scrofulous  diathesis,  by  undernutrition,  general  weakness 
and  convalescence  from  disease.  In  adults,  overexertion,  general 
nutritional  disturbances,  such  as  diabetes  and  cachexia,  likewise 
create  a  predisposition  for  pyodermatitides.  The  part  played  by 
local  circulatory  disturbances  or  nutritional  disturbances  of  the  skin 
manifests  itself  for  example  in  varicose  limbs.  These  factors  explain 
not  only  the  easy  onset  of  superficial  pyodermatitides  but  also 
their  multiplication,  their  liability  to  recurrence,  their  obstinate 
character  and  the  tendency  to  complications  with  lymphangitis, 
abscesses,  adenitis  and  to  termination  in  the  grave  forms  of  staphy- 
lococcia and  streptococcia  which  may  lead  to  death  in  weakly 
children  and  cachectic  individuals. 

D.  Staphylococci  and  streptococci  both  possess,  undoubtedly 
due  to  their  secretions,  a  vasodilator  action  and  an  attraction  for 
leukocytes  known  as  positive  chemotaxis.  Under  their  influence  the 
skin  becomes  congested  and  the  white  corpuscles  swarm  into  the 
cutis,  or,  according  to  the  case,  into  the  epidermis,  together  with  a 
certain  amount  of  plasma.  Certain  differences  are  noted,  however, 
between  the  properties  of  the  two  groups  of  pyococci. 

The  staphylococci  attract  especially  the  polynuclears  and  pro- 
duce the  smooth,  creamy,  thick  pus  which  was  formerly  described 
as  "laudable  pus."  The  streptococci  are  in  a  general  way  less 
pyogenic;  they  give  rise  rather  to  an  outflow  of  plasma  and  the 
secretion  of  a  turbid  serous  fluid  or  of  thin  serous  pus.  However, 
according  to  Jadassohn,  staphylococci  may  also  give  rise  to  serous 
bullae.  The  Staphylococcus  aureus,  moreover,  possesses  necrotizing 
properties,  as  shown  by  the  core  of  furunculus  and  the  slough  of 
carbuncle.    Mixed  infection  produces  intermediate  effects. 

Clinical  Forms. — A  series  of  pathological  types  is  referable  to  the 
penetration  of  pyococci  into  the  epidermis,  into  the  pilosebaceous 
follicles,  or  into  the  cutis.  I  have  endeavored  to  convey  an  idea  of 
the  principal  types  in  the  subjoined  schematic  figures  (see  Plate  II). 

Among  the  staphylococcic  pyodermatitides  of  external  origin,  I 
have  already  described  Bockhardt's  impetigo,  impetiginous  eczema, 
ostiofollicular  pustules  and  deep  folliculitis,  sycosis,  etc.  Furun- 
culus, carbuncle  and  hidrosadenitis  will  be  discussed  further  on. 


540       INFECTIO I  >'  DERMA  TOSES  -PYODERMA  Tl TIDES 

Abscesses,  diffuse  phlegmons  [cellulitis]  and  suppurating  wounds 
belong  to  the  domain  of  surgery. 

Staphylococci  brought  to  the  skin  by  way  of  the  blood  give  rise 
to  multiple  and  successive  emoblic  abscesses,  as  one  of  the  mani- 
festations of  pyemia,  which  is  accompanied  by  grave  general 
disturbances. 

I  have  previously  had  occasion  to  state  that  the  miliary  abscesses 
of  little  children  are  not  referable  to  the  last  named  pathogenesis, 
as  formerly  believed  to  be  the  case,  but  that  they  are  the  result 
of  an  ascending  infection  of  the  sudoriparous  canals. 

I  repeat  that  an  association  of  various  pyococci  may  be  held 
responsible  for  impetigo  vulgaris  and  ecthyma  (pp.  165,  169),  for 
various  ulcers  (XV),  probably  for  pustular  acne  (p.  386),  the  microbic 
eczemas  (p.  66)  and  the  eczematides  (p.  97),  as  well  as  for 
impetiginous  onyxis  (p.  434). 

Referable  to  cutaneous  streptococci  a  are:  the  impetigo  of  Tilbury 
Fox,  ecthyma,  leg  ulcer,  erysipelas  (which  is  not  usually  considered 
in  the  scope  of  dermatology),  the  lymphangitides,  lymphangitic 
abscesses,  phlegmons  and  adeno-phlegmons,  which  belong  to  the 
domain  of  surgery. 

Perleche. — Perleche — a  very  trifling  affection,  interesting  on 
account  of  its  contagiousness  and  the  diagnostic  errors  which  it 
occasions — consists  of  a  circumscribed  redness  of  the  two  labial 
commissures,  with  maceration  of  the  epidermis  and  often  fissure- 
formation.  It  is  frequent  in  children  who  contract  it  in  school  and 
transmit  it  to  the  family;  it  may  last  for  weeks  and  months.  Some- 
times it  coexists  with  impetigo  vulgaris  or  impetiginous  stomatitis. 

Perleche  seems  to  be  a  simple  regional  streptococcia.  By  J. 
Lemaitre,  who  described  it  in  1886,  it  was  attributed  to  a  so-called 
Streptococcus  plicatilis,  which  is  probably  in  no  way  specific. 

A  differential  diagnosis  must  be  made  from  herpes,  which  is 
rarely  bilateral  and  always  vesicular  at  the  onset;  and  especially 
from  mucous  patches,  but  these  are  accompanied  by  other  manifes- 
tations of  secondary  syphilis. 

Perleche  is  treated  like  impetigo.  Silver  nitrate,  Alibour  water, 
yellow  precipitate  ointment,  or  steresol,  etc.,  will  promptly  check 
it.  The  children  must  not  be  allowed  to  kiss  and  their  glasses  and 
tableware  should  be  washed  in  boiling  water. 

Finally,  there  occurs  nonsuppurative  manifestations  of  the  various 
pyococcias,  such  as  certain  purpuras  (Chapter  III),  probably  botryo- 
mycoma  (p.  704)  and  perhaps  the  necrotic  and  keloid  forms  of  acne,  etc. 

Furunculus. — A  furuncle  or  boil  is  a  massive  folliculitis  with  a 
usually  very  acute  inflammatory  course  and  necrotic  character. 
Boils  are  due  to  the  Staphylococcus  aureus,  as  discovered  in  1880 


PYODERMATITIDES  541 

by  Pasteur,  who  soon  afterward  was  able  to  demonstrate  the 
"microbe  of  furuncle"  in  osteomyelitis. 

Whether  it  be  derived  from  a  contagion,  or  what  is  more  common, 
from  auto-inoculation  of  another  staphylococcic  lesion,  the  microbe 
must  necessarily  have  been  introduced  rather  deeply  into  the  follic- 
ular canal  in  order  to  produce  a  furuncle.  Hence,  boils  preferably 
develop  in  regions  exposed  to  rubbing  from  clothes  or  implements  of 
work;  they  are  common  in  rag-pickers,  refiners,  mechanics,  riders, 
etc.  Fatigue,  nervous  disturbances,  errors  in  diet  and  convalescence 
from  acute  diseases  are  predisposing  factors.  Diabetes  mellitus 
especially  constitutes  such  a  favorable  soil  that  the  urine  should  be 
examind  as  a  routine  procedure  in  all  cases  of  furunculosis. 

In  certain  individuals,  through  the  effect  of  a  very  marked  pre- 
disposition or  rather  because  immunization  does  not  occur  as  under 
normal  conditions,  boils  follow  one  another  for  a  period  of  months 
and  years.  This  furunculosis  may  be  connected  with  a  run-down 
condition,  auto-intoxications,  etc.;  but  its  cause  often  remains 
undemonstrable. 

A  furuncle  begins  with  a  red  acuminate  elevation  with  a  hair  in 
its  center;  its  two  essential  features  are  induration  and  pain.  There 
is  often  considerable  edema  of  the  vicinity.  In  three  to  five  days, 
the  growing  protuberance  has  assumed  a  purplish,  later  pustular 
apex.  Having  reached  maturity,  the  furuncle  softens  and  opens; 
after  a  flow  of  pus,  a  core  or  slough  is  eliminated,  consisting  of 
necrotic  cellular  tissue  infiltrated  with  pus.  The  pain  subsides  as 
soon  as  the  discharge  of  pus  is  freely  established. 

A  furuncle  always  leaves  a  more  or  less  visible  cicatrix,  unless  it 
has  been  aborted,  spontaneously  or  as  the  effect  of  treatment;  in 
this  case,  the  induration  lasts  from  three  to  twelve  days  and  finally 
becomes  absorbed.  In  weakened  or  diseased  persons,  boils  are 
accompanied  by  extensive  edema,  fever,  malaise,  etc. 

Boils  may  be  situated  wherever  there  are  hair  follicles,  but  the 
site  of  election  is  at  the  nape  of  the  neck;  next  in  order  follow  the 
back,  the  buttocks,  the  lower  limbs,  the  forearms,  etc. 

Furuncle  of  the  upper  lip  gives  rise  to  a  severe  and  very  alarming 
inflammatory  tumefaction,  and  the  possibility  of  lymphangitis, 
phlebitis  and  meningeal  complications  must  be  borne  in  mind. 

Furuncles  of  the  auditory  meatus  are  noteworthy  on  account  of  the 
resulting  pain,  which  is  very  severe,  radiates  widely,  interferes  with 
mastication  and  prevents  sleep.  These  furuncles  are  often  asso- 
ciated with  auricular  eczema;  they  have  a  tendency  to  recur  and 
may  affect  one  ear  after  the  other. 

A  furuncle  differs  from  ordinary  suppurative  folliculitis  by  the 
severity  of  the  inflammatory  reaction,  the  induration  of  the  tissues, 
the  pain  and  the  core  or  slough.    It  is  distinguished  from  hidros- 


542         INFECTIOUS  DERMATOSES— PYODERMATITIDES 

adenitis,  which  moreover  is  practically  limited  to  the  axilla,  by  its 
acuminate  form  and  by  its  core.  The  differential  diagnosis  from 
malignant  pustule  [anthrax]  may,  in  exceptional  cases,  prove  some- 
wliat  difficult. 

Treatment. — At  the  onset,  abortive  treatment  may  be  tried;  for 
this  purpose,  a  finely  pointed  galvanocautery  or  thermocautery 
needle  may  be  inserted  in  the  center  of  the  furuncle,  or  it  may  be 
painted  twice,  at  an  interval  of  twelve  hours,  with  iodin  tincture 
or  iodo-acetone.  The  adjacent  skin  should  be  cleaned  with  an 
antiseptic  soap  and  washed  with  camphorated  or  resorcinated  alcohol. 

In  its  developed  stage,  the  furuncle  must  not  be  irritated  by 
strong  antiseptics,  which  would  cause  a  complicating  artificial  der- 
matitis, without  any  benefit  whatever.  It  suffices  to  make  two  daily 
applications  of  a  hot  spray  with  weak  carbolic,  resorcin,  or  pheno- 
salyl  water,  or  simply  washing  with  Alibour  water;  the  parts  are 
then  covered  with  cotton  wadding,  moist  dressings  with  boiled  water, 
or  still  better  with  a  layer  of  cotton  covered  with  borated  starch 
glycerolate  (1  to  10),  which  affords  a  better  protection  against 
neighborhood  inoculations. 

I  have  never  found  it  necessary  to  incise  a  furuncle.  It  would  be 
more  justifiable  to  perform  complete  excision  at  the  onset,  provided 
the  patient  and  the  locality  permit.  The  pain  caused  by  interstitial 
injections,  even  with  gaseous  oxygen  is  not  offset  by  their  advan- 
tages. In  the  period  of  repair,  it  is  advisable  to  cover  the  orifice 
with  mercurial  plaster  or  with  yellow  oxide  of  mercury  salve  or  a 
piece  of  gauze. 

[An  attempt  to  abort  a  boil  by  the  accurate  application  of  a  solu- 
tion of  iodin  to  its  apex,  repeated  three  times  with  twelve-hour 
intervals,  should  always  be  made  at  the  inception  of  the  process.  It 
is  useless  when  there  is  already  a  considerable  induration.  In  cases 
of  furunculosis  every  follicular  inflammation,  even  the  most  insig- 
nificant, should  be  regarded  as  suspect  and  treated  abortively.  I 
agree  with  the  author  in  condemning  incision  of  a  boil;  it  is  bad 
practise,  painful  and  useless.  I  earnestly  recommend  the  following 
treatment:  the  affected  area  is  washed  with  alcohol  or  1  to  2000 
bichlorid  alcohol.  The  boil  is  then  covered  with  a  3  to  4  cm.  square 
of  salicylic  acid  plaster  made  according  to  the  formula  of  Dr. 
Klotz:  1$  empl.  diachyli  00.0,  empl.  saponis  25.0,  cerse  2.0,  vaselini 
8.0,  acidi  salicylici  5.0,  M.  ft  empl.  secundam  artem.  This  plaster 
mass  rolled  in  sticks  for  convenience  is  spread  as  required,  smooth, 
even  and  thin  on  cotton-sheeting  (muslin)  and  applied  over  the 
boil.  It  is  soothing,  protective  and  sufficiently  occlusive  while  not 
adhering  firmly  enough  to  cause  retention  of  pus.  It  should  be 
removed  twice  a  day,  the  free  pus  very  gently  squeezed  out,  the 
surface  washed  with  a  mild  antiseptic  and  fresh  plaster  applied.    In 


PYODERMATITIDES  543 

cases  of  furunculosis  I  employ  the  stock  vaccines,  four  or  five  injec- 
tions at  intervals  of  three  to  five  days.] 

Internal  treatment,  with  colloidal  sulphur,  sulphuric  acid  lemon- 
ade, sulphur  compounds,  hyposulphites,  ichthyol,  etc.,  is  very 
variably  estimated.  Beer-yeast,  preferably  fresh,  in  doses  of  three 
tablespoonfuls  daily,  not  infrequently  produces  a  sudden  subsidence 
of  the  inflammation  and  the  pain.  When  it  fails,  beer-yeast  from 
another  source  should  be  tried,  or  it  may  be  replaced  with  a  different 
ferment,  for  example  a  lactic  ferment. 

In  furunculosis  the  vaccine  therapy  of  A.  E.  Wright,  even  with 
a  stock  vaccine  of  Staphylococcus  aureus,  constitutes  an  excellent 
although  sometimes  unreliable  method  of  treatment. 

Care  must  of  course  be  taken  to  correct  the  patient's  hygiene; 
the  dietetic  regimen  indicated  in  diabetes,  auto-intoxication,  arthri- 
tism,  etc.,  may  be  called  for  in  some  cases.  A  cure  at  watering 
places  with  sulphur  or  arsenical  springs  is  sometimes  very  useful  in 
obstinate  cases  of  furunculosis. 

Systematic  treatment  of  furuncle,  furunculosis  and  other  staphy- 
lococcias with  pure  metallic  powdered  zinc  mixed  with  zinc  oxide, 
in  doses  of  4  to  8  grams  daily,  as  recently  introduced  by  Frouin  and 
Gregoire,  is  extremely  simple  and  sometimes  seemed  to  be  efficient 
in  my  experience. 

Carbunculus.— Carbuncle  (French,  anthrax)  may  be  considered  as 
an  agglomeration  of  furuncles.  The  etiology  is  the  same  as  that  of 
furuncle.  Garre  successfully  produced  a  carbuncle  through  inocu- 
lation of  staphylococci  derived  from  a  case  of  osteomyelitis. 

The  lesions  are  more  extensive  than  those  of  furuncle;  the  necrosis 
of  the  perifollicular  cellular  tissue  becomes  confluent  in  large  areas 
which  are  finally  detached  by  the  suppuration  and  appear  no  longer 
in  form  of  circumscribed  sloughs  but  under  the  aspect  of  sometimes 
very  extensive  gangrenous  shreds. 

[The  differences  between  carbuncle  and  furuncle  are  not  simply 
a  matter  of  degree.  The  phlegmonous  inflammation  in  furuncle 
starting  in  a  follicle  always  remains  definitely  circumscribed  in  a 
globular  form,  with  the  follicle  as  its  center,  though  it  may  extend 
as  far  as  the  hypoderm.  In  carbuncle  a  similar  infection  extends 
into  the  hypoderm  and  then  spreads  to  a  greater  or  less  extent 
laterally  in  the  hypoderm  ascending  by  the  path  of  the  columnae 
adiposes  to  the  surface  where  it  appears  as  a  group  of  secondary 
furunculoid  elevations  in  the  neighborhood  of  the  primary  furuncle. 
A  carbuncle  is  always  a  grave  affection  because  it  is  capable  of 
indefinite  lateral  extension  in  the  hypoderm.] 

The  onset  is  often  marked  by  chills,  malaise,  general  prostration, 
anorexia,  while  at  the  same  time  a  very  hard  red  swelling  makes  its 
appearance,  which  is  the  seat  of  severe  tearing  pain.    The  neighbor- 


544         INFECTIOUS  DERMATOSES— PYODERMATITIDES 

ing  edema  is  usually  considerable  and  very  extensive.  At  the  end 
of  lour  or  five  days  a  few  small  vesicles  or  pustules  manifest  them- 
selves  at  the  follicular  orifices  of  the  carbuncle;  these  become  trans- 
formed into  openings  or  craters  from  which  pus  escapes  in  increasing 
amounts  and  the  grayish  necrotic  masses  are  subsequently  evacu- 
ated. The  skin  between  the  orifices  is  purplish  and  swollen,  often 
eroded;  the  bridges  separating  the  orifices  are  often  destroyed  by 
purulent  disintegration  or  necrosis.  The  openings  of  a  carbuncle  are 
accordingly  multiple,  irregular  and  winding.  The  period  of  evacua- 
tion lasts  from  a  fortnight  to  a  month.  Spontaneous  pain  ceases  as 
soon  as  the  deep  sloughing  reaches  its  limit.  Repair  takes  place  by 
granulation;  it  leaves  a  very  noticeable,  often  retracted  and  stellate 
cicatrix. 

In  weakened  patients,  or  in  diabetics,  etc.,  the  woody  indura- 
tion at  the  onset  of  a  carbuncle  may  attain  enormous  proportions 
(woody  phlegmon  of  the  aged).  In  the  period  of  suppuration,  enor- 
mous winding  cavities  and  purulent  tracts  are  formed  and  sometimes 
large  gangrenous  patches.  These  diffuse  or  malignant  carbuncles  are 
accompanied  by  high  fever,  excitement,  wild  delirium  or  profound 
depression;  they  may  lead  to  death  through  septicemia,  hectic 
fever,  or  by  rupture  of  large  vessels  or  opening  into  large  cavities. 

The  prognosis,  which  is  very  variable,  would  seem  to  depend 
either  on  the  virulence  of  the  infection  or  on  the  character  of  the 
soil.  The  duration  of  a  moderately  severe  carbuncle  is  from  a 
month  to  six  weeks. 

The  treatment  of  benign  carbuncle  is  patterned  on  the  treatment 
of  furuncle.  Incision  is  rarely  necessary  or  advisable.  In  large  car- 
buncles, the  introduction  of  sticks  of  Canquoin's  paste  (therapeutic 
notes,  §  11)  evidently  shortens  the  total  duration  of  the  process. 
The  treatment  of  malignant  carbuncle  belongs  to  the  domain  of 
surgery. 

Hidrosadenitis. — The  hidrosadenitis  of  Verneuil,  or  tuberous 
abscesses  of  the  axilla  of  Velpeau,  are  intradermic  or  subdermic 
abscesses,  the  size  of  an  almond  to  that  of  a  large  nut  or  more,  which 
occur  exclusively  in  the  axillary  region. 

These  abscesses  are  more  common  in  women,  developing  espe- 
cially in  cases  of  intertrigo,  lack  of  cleanliness,  hyperidrosis,  but 
principally  of  axillary  eczematides. 

One  or  more  indurations  develop,  usually  without  general  dis- 
turbances, with  a  sensation  of  pruritus,  tension  and  distress.  These 
indurations  are  perceptible  on  palpation,  which  is  painful;  gradu- 
ally they  form  a  demonstrable,  hemispherical,  red,  non-acuminate 
prominence. 

They  may  undergo  absorption,  but  more  frequently  they  soften 
and  open  through   the  thinned   and  reddened  skin,   emptying  a 


PYODERM  ATI  TIDES  545 

creamy  pus,  but  usually  no  slough.  The  development  of  each 
nodule  lasts  from  ten  to  fifteen  days;  they  succeed  each  other,  some- 
times in  both  axillae,  for  weeks  and  months.  The  affection  has  a 
tendency  to  recur  each  summer.    Complications  are  rare. 

On  account  of  the  differences  in  appearance  and  course,  as  well 
as  the  usual  non-coincidence  of  these  tuberous  abscesses  with  fu- 
runcles in  other  regions,  they  are  believed  to  be  due  to  a  staphy- 
lococcus infection  of  the  [large  axillary]  sudoriparous  glands  rather 
than  of  the  pilosebaceous  follicles. 

The  treatment  is  the  same  as  that  of  furuncle.  The  hairs  of  the 
region  should  not  be  cut  or  shaved.  I  have  known  beer-yeast  or 
various  ferments  work  wonders  in  cases  of  protracted  duration;  the 
same  remark  applies  to  the  modern  treatment  with  zinc.  Vaccine- 
therapy  is  also  indicated  and  sometimes  very  successful.  Scrupulous 
cleanliness  is  required  to  guard  against  recurrences. 


35 


CHAPTER  XXVII. 
INFECTIOUS  BACILLARY  DERMATOSES. 

The  infectious  dermatoses  caused  by  bacilli  are:  cutaneous  tuber- 
culosis; leprosy,  glanders,  malignant  pustule  or  anthrax,  cutaneous 
diphtheria,  soft  chancre  and  probably  also  the  verruga  [Peruana] 
of  Carrion  and  rhinoscleroma. 

A  number  of  other  affections  have  also  been  attributed  to  specific 
or  non-specific  bacilli,  pure  or  associated,  for  instance,  with  spirilla 
(fuso-spirillary  symbiosis),  as  follows: 

Wound-diphtheria  and  hospital  gangrene,  which  belong  to  the 
domain  of  surgery;  tropical  phagedenic  ulcer  (p.  301,  ulcero-mem- 
branous  stomatitis  (p.  306),  noma  (p.  308)  and  balanoposthitis 
erosiva  circinata  (p.  311). 

TUBERCULOSIS. 

The  cutaneous  manifestations  of  tuberculosis  constitute  at  the 
present  day  an  important  chapter  in  dermatology.  This  chapter 
has  only  gradually  been  built-up  and  had  no  scientific  basis  before 
the  discoveries  of  Villemin  and  Koch. 

Thus  lupus  vulgaris  which  had  been  distinguished  from  the  other 
dermatoses  by  Willan  and  Bateman,  was  named  tuberculous  only 
because  its  characteristic  lesion  belongs  to  the  class  of  tubercles,  in 
the  dermatological  sense  of  this  term.  Clinicians — Lugol,  Bazin, 
Hardy,  Lallier,  Vidal  and  Besnier- — grouped  it  among  the  scrofulides 
and  more  or  less  clearly  surmised  its  tuberculous  character.  This 
was  demonstrated  histologically  by  Friedlander  and  others,  experi- 
mentally by  Max  Schiiller,  Leloir  and  especially  by  R.  Koch. 

The  evolution  of  our  views  in  regard  to  the  other  types  of  cuta- 
neous tuberculosis  has  undergone  analogous  changes. 

Among  the  features  on  which  a  diagnosis  of  a  cutaneous  tuber- 
culosis is  based  at  the  present  day,  only  two  have  a  positive  scien- 
tific value,  namely : 

1.  The  presence  of  Koch's  bacillus  in  the  lesions. 

2.  The  positive  outcome  of  inoculation  of  the  affected  tissue  into 
animals,  especially  guinea-pigs  which  are  sensitive  to  this  infection. 

The  other  features  permit  merely  a  presumptive  conclusion, 
although  of  considerable  weight  when  several  are  present.  Such 
features  are: 

1.  A  histological  structure  in  conformity  with  that  of  known 
tuberculous  lesions. 


TUBERCULOSIS  547 

2.  A  positive  local  reaction  to  Koch's  tuberculin  A. 

3.  A  certain  clinical  appearance  and  course  and  special  etiological 
factors. 

4.  The  coexistence  of  undoubtedly  tuberculous  manifestations. 
A  serodiagnosis  of  tuberculosis  unfortunately  is  not  possible. 
Clinical  Forms. — Five  pathological  types  are  known  which  in  a 

general  way  satisfy  these  conditions  and  almost  regularly  present 
the  six  features  enumerated  above :  Tuberculous  ulcer,  tuberculosis 
verrucosa,  tuberculous  gumma,  fungoid  tuberculosis  and  lupus  vulgaris. 
I  grouped  these  together  under  the  generic  heading  of  "cutaneous 
tuberculoses." 

The  contributions  of  the  last  thirty  years  have  shown  that  there 
exists  in  addition  a  considerable  group  of  dermatoses  which  without 
usually  fulfilling  the  first  two  conditions  so  frequently  comply  with 
the  four  latter  as  to  justify  the  surmise  of  a  close  connection  existing 
between  them  and  tuberculosis. 

These  dermatoses  I  have  named  tuberculides  and  the  majority  of 
modern  authors  interpret  them,  like  myself,  as  attenuated  tuber- 
culoses. It  is  only  the  limitations  to  be  made  to  this  group  that  is 
still  a  subject  of  discussion. 

It  must  be  emphasized  from  the  start  that  while  this  classification 
and  these  subdivisions  are  justified  in  the  great  majority  of  the 
cases  and  considerably  facilitate  their  description  and  study,  never- 
theless numerous  transition  forms  are  met  with  between  the  various 
types  of  cutaneous  tuberculoses  as  well  as  between  these  and  the 
tuberculides.  The  existence  of  transitions  between  the  various 
manifestations  of  the  same  cause  is  in  no  way  remarkable. 

General  Etiology  and  Pathogenesis. — It  would  involve  an  encroach- 
ment upon  the  domain  of  general  pathology  to  describe  in  this 
connection  the  Koch  bacillus,  to  study  its  biological  properties, 
its  cultures,  its  secretions,  its  pathogenic  properties  in  man  and  in 
animals,  its  portals  of  entry  and  the  modifications  apparently 
wrought  in  the  course  of  the  resulting  disease  through  the  properties 
of  the  affected  territory.  It  is  sufficient  to  emphasize  the  great 
extension  of  the  field  of  tuberculosis  through  modern  investigations. 
This  infection  at  the  present  day  appears  to  be  infinitely  more  widely 
distributed  than  was  formerly  believed. 

It  is  in  reality  essentially  an  infection  of  childhood.  When  it 
attacks  the  newborn,  which  is  rare,  the  patients  almost  invariably 
die.  In  the  course  of  late  childhood,  the  number  of  infected  indi- 
viduals rapidly  increases  until,  according  to  Naegeli,  it  reaches  the 
proportion  of  96  per  cent,  shortly  after  puberty.  By  no  means  all 
of  these  cases  succumb  to  phthisis,  meningitis  or  tuberculous  septi- 
cemia; the  majority  resist  the  infection.  When  the  initial  lesions 
heal,  various  contingencies  may  arise :  the  tuberculosis  may  become 


548  INFECTIOUS  BACILLARY  DERMATOSES 

entirely  latent,  only  the  tuberculin  reaction  or  possibly  the  autopsy 
being  capable  of  revealing  its  existence.  Or  sometimes,  so-called 
manifestations  of  local  tuberculosis  may  persist  or  develop  later  on 
(glandular,  bony,  articular  or  cutaneous),  constituting  the  "  scrofula" 
of  the  older  writers;  furthermore  recrudescences  or  the  onset  of  new 
manifestations  may  occur  at  any  time  of  life. 

The  influences  which  determine  the  course  taken  by  the  tuber- 
culous infection  are  multiple  and  imperfectly  known.  One  may 
incriminate  the  nature  of  the  organic  soil,  the  general  hygienic 
conditions,  the  action  of  certain  infections  such  as  measles,  etc., 
the  effect  of  overwork,  repeated  pregnancies,  etc.,  but  the  principal 
factor  in  recrudescences  and  in  the  development  of  new  lesions 
undoubtedly  is  re-infection  or  superinfection  of  heterogenous  or 
autogenous  origin. 

It  has  been  experimentally  demonstrated,  however,  that  the  re- 
infection of  an  organism  invaded  by  the  tubercle  bacillus  does  not 
produce  the  same  effects  as  the  first  inoculation,  but  different  effects; 
this  is  known  as  the  allergy  of  von  Pirquet. 

The  subcutaneous  inoculation  of  virulent  Koch's  bacilli  into  an 
animal  of  a  very  sensitive  species,  like  the  guinea-pig,  produces  at 
the  end  of  ten  or  twenty  days  a  nodosity  which  undergoes  ulceration, 
/'.  e.,  the  tuberculous  chancre;  this  is  followed  by  glandular  enlarge- 
ment, then  regularly  by  a  generalized  visceral  tuberculosis  affecting 
chiefly  the  spleen  and  the  liver,  from  which  the  animal  dies.  Experi- 
ments on  monkeys,  in  Java,  in  1905,  under  the  direction  of  Xeisser, 
furnished  practically  identical  results  irrespective  of  the  source  of 
the  tuberculous  virus. 

When  an  already  tuberculized  guinea-pig  is  re-inoculated  with 
bacilli  at  another  point  of  the  skin,  preferably  between  four  and  six 
weeks  after  the  first  infection,  the  immediate  result  is  an  ecchymosis 
and  a  slough  which  falls  off  leaving  a  wound  which  heals  without 
corresponding  glandular  enlargement;  this  is  known  as  Koch's 
phenomenon  ( L891  )  and  constitutes  a  particular  instance  of  allergy. 

In  animals  of  more  resistant  species,  this  allergy  manifests  itself 
differently  and  the  same  is  undoubtedly  true  for  man. 

Returning  to  human  cutaneous  tuberculosis,  with  which  alone 
we  are  here  concerned,  the  following  points  must  not  be  lost  sight 
of:  the  individuals  in  which  it  is  met  with  are  practically  all  pre- 
viously infected  with  tubercle  bacilli;  the  re-infecting  agent  may 
he  of  exogenous  or  autogenous  origin,  according  as  new  bacilli  come 
from  the  outside  or  from  a  focus  of  tuberculosis  borne  by  the  patient 
himself;  in  the  latter  case,  the  cutaneous  re-infection  may  occur 
through  contiguity  (derived,  for  example,  from  a  subjacent  bony  or 
glandular  tuberculosis),  or  it  may  result  from  a  metastasis  through 
the  lymphatic  route  or  the  blood  route. 


TUBERCULOSIS  549 

These  pathogenic  conditions  perhaps  play  a  certain  part  in  the 
diversity  of  aspect  and  course  of  the  cutaneous  lesions,  although  a 
smaller  one  than  that  pertaining  to  the  existing  state  of  allergy. 

The  question  has  arisen  as  to  whether  the  origin  and  strain  of  the 
bacillus  may  not  be  concerned  in  the  production  of  these  differences. 
The  bovine  bacillus  has  occasionally  been  found,  in  cases  of  lupus 
for  instance,  more  often  in  London  and  New  York  than  in  Paris; 
but  the  human  bacillus  is  usually  responsible.  Burnet  has  noted 
some  instances  of  human  bacilli  of  attenuated  virulence  in  cutaneous 
lesions.    Investigations  of  this  question  are  still  under  way. 

At  any  rate,  however,  it  must  be  admitted  that  although  the 
reasons  are  not  understood,  tuberculosis  of  the  skin  manifests  itself 
in  lesions  of  very  different  form. 

I  shall  review  the  principal,  most  common  and  most  definite  of 
these  lesions,  noting  that  they  have  been  arranged  on  a  diminishing 
scale  of  clinical  malignancy  and  bacillary  content. 

Cutaneous  Tuberculosis.  —  Tuberculous  Ulcer.  —  This  name  is 
restricted  to  a  primarily  and  essentially  ulcerative  lesion  (p.  288) 
due  to  the  Koch  bacillus,  which  is  abundantly  present.  This  affec- 
tion has  also  received  the  names  of  miliary  tuberculosis  of  the  skin 
and  mucous  membranes;  and  acute  tuberculous  dermatitis. 

Ulcerated  lupus,  open  tuberculous  gumma,  scrofula  and  fistulas 
derived  from  tuberculous  osteitis,  etc.,  do  not  fall  under  this  defi- 
nition. 

It  was  in  the  mouth  and  notably  on  the  tongue  that  tuberculous 
ulcer  was  first  distinguished  from  analogous  lesions  by  Ricord  and 
subsequently  studied  by  Julliard,  Trelat,  Fereol,  etc.  The  observa- 
tions of  Coyne,  of  Jarisch  and  Chiari,  showed  that  it  occurred  also 
on  the  integument  under  an  identical  form. 

As  a  rule,  tuberculous  ulcer  is  observed  only  in  already  badly 
infected  adults,  notably  in  consumptives. 

It  has  two  seats  of  election:  in  the  mouth,  on  the  lips,  tongue, 
the  inner  aspect  of  the  cheeks,  the  pharynx,  or  in  the  circumference 
of  the  mouth  and  nostrils;  or  at  the  anus  and  its  surroundings.  It 
is  rare  on  the  genital  organs,  but  may  be  found  there  and  give  rise 
to  serious  difficulties  in  diagnosis. 

These  localizations  and  the  common  preliminary  of  an  open  tuber- 
cular lesion  of  the  lung,  larynx,  or  intestines,  in  the  same  patient, 
are  suggestive  of  the  fact  that  tuberculous  ulcer  is  generally  refer- 
able to  auto-inoculation  of  some  fissure  or  erosion  with  bacilli  from 
the  sputum  or  the  feces. 

Sometimes,  however,  it  is  the  result  of  contagion.  I  have  observed 
it  on  the  forehead  of  an  apparently  healthy  woman,  the  wife  of  a 
consumptive.  Cases  such  as  those  reported  by  Lehmann,  who  saw 
ten  healthy  children  become  infected  with  tuberculous  ulcers  of 


550  INFECTIOUS  BACILLARY  DERMATOSES 

the  penis  by  the  mouth  of  a  tuberculous  rabbi,  in  the  course  of  ritual 
circumcision,  seem  to  me  to  be  instances  of  primary  tuberculous 
chancre,  comparable  to  the  chancre  of  newly  inoculated  guinea-pigs, 
but  not  tuberculous  ulcers  like  those  of  consumptives. 

At  the  onset  of  a  tuberculous  ulcer,  the  lesion  consists  of  one  or 
several  elevations  of  a  dusky  red  color,  which  become  lighter  and 
finally  evacuate  their  contents  externally.  The  orifices  become 
confluent  and  the  ulcer  extends  rapidly  on  the  surface,  but  slowly 
in  depth. 

I  have  previously  described  its  typical  features  in  its  fully  de- 
veloped stage  (page  288),  a  few  of  its  most  common  clinical 
varieties,  as  well  as  the  grounds  on  which  the  diagnosis  rests;  the 
reader  is  also  referred  to  the  description  of  atypical  tuberculous 
ulcers  elsewhere  in  this  book  (p.  291). 

Treatment. — In  a  consumptive  patient,  it  suffices  to  touch  the 
ulcer  with  camphorated  naphthol,  lactic  acid,  peroxide  water, 
methylene-blue,  or  with  a  mixture  containing  iodoform;  the  pain 
must  be  controlled  with  cocain;  if  dressings  are  applicable,  iodoform 
or  one  of  its  substitutes,  dermatol,  airol,  europhen,  etc.,  should  be 
employed. 

If  the  patient  does  not  appear  to  be  tuberculous  or  only  slightly  so, 
the  total  removal  of  the  lesion  is  indicated,  or  in  default  of  this, 
scraping  followed  by  cauterization  with  the  thermocautery  and 
appropriate  dressings. 

Tuberculous  Gummas. — These  are  subcutaneous  nodes  or  nodosi- 
ties due  to  the  Koch  bacillus,  which  may  be  demonstrated  in  variable 
numbers.  Their  course  tends  toward  softening  and  evacuation. 
They  have  been  described  elsewhere  (p.  268). 

They  are  encountered  preferably,  but  not  exclusively,  in  patients 
in  a  bad  general  condition,  suffering  from  visceral  tuberculosis  or 
especially  from  bony  or  glandular  tuberculosis.  Children  and 
youthful  individuals  are  more  particularly  susceptible. 

The  treatment  of  tuberculous  gummas  varies  according  to  their 
seat,  their  number  and  the  general  condition  of  the  patient.  When 
they  can  be  extirpated  surgically  at  an  early  date  this  is  the  most 
advisable  procedure.  Puncture  followed  by  alterative  injections 
rarely  yields  good  results.  When  the  gumma  is  open,  it  may  be 
touched,  after  scraping  if  necessary,  with  iodin  solution.  Cam- 
phorated naphthol,  iodoform-ether,  guai'acol-oil,  etc.,  followed  by 
the  application  of  dry  or  gomenol-oil  dressings. 

Tuberculosis  Verrucosa. — The  term  tuberculosis  verrucosa,  in  ordi- 
nary use  since  the  very  complete  investigations  of  this  derma- 
tological  type  by  Riehl  and  Paltauff  in  1886,  has  replaced  the  terms 
verrucous  scrofulide  (Hardy,  1800),  lupus  verrucosus  (MacCall 
Anderson,    1877)    and   sclerotic   papillomatous   lupus    (Vidal    and 


TUBERCULOSIS 


551 


Leloir,  1882),  which  more  or  less  closely  corresponded  to  it.  The 
condition  was  very  thoroughly  discussed  by  H.  Moutot,  in  his 
These  de  Lyon,  1907  (Fig.  167). 

Elsewhere  in  this  book  I  have  recorded  the  clinical  description 
of  the  lesions  and  pointed  out  their  usual  site  (page  247).  The 
patches  are  sometimes  multiple. 

Tuberculosis  verrucosa  results  in  the  great  majority  of  the  cases 
from  an  external  inoculation. 

It  is  observed  in  consumptives  as  the  result  of  auto-inoculation  of 
their  sputum  or  dejecta;  on  the  other  hand,  in  nurses,  butchers  and 
veterinaries,  who  through  their  occupation  come  in  contact  with 
tuberculous  individuals,  human  or  animal.  It  may  be  derived  from 
an  auto-infection  of  the  skin  by  a  focus  of  bony,  articular,  or 
tendinous  tuberculosis.     Tuberculous  lymphangitis,  which  usually 


Fig.  167. — Tuberculosis  cutis  verrucosa. 


assumes  a  gummous  or  fungoid  type,  sometimes  presents  a  verrucous 
character.  A  few  scanty  Koch's  bacilli  may  be  found  in  the  sections; 
guinea-pig  inoculation  is  usually  positive.  Some  authors  believe 
that  tuberculosis  verrucosa  is  due  especially  to  a  bovine  bacillus; 
according  to  others,  a  human  bacillus  is  more  commonly  demon- 
strable. 

The  onset,  which  usually  escapes  notice,  is  in  the  form  of  a  small, 
hard,  horny  nodule  which  frequently  suppurates  and  becomes  an 
abscess.   The  development  of  the  lesions  is  centrifugal  or  serpiginous. 

Lupus  tubercles  are  never  demonstrable  in  the  developed  stage, 
but  I  have  noted  their  appearance  in  the  subsequent  cicatrix. 

The  duration  is  very  protracted  and  indefinite.  The  patch  may 
become  partially  cicatrized,  but  a  complete  spontaneous  cure  is  rare. 
Tuberculosis  verrucosa  may  lead  to  lymphatic  propagation  and 
visceral  generalization;  it  accordingly  constitutes  a  serious  lesion. 


552  INFECTIOUS  BACILLARY  DERMATOSES 

Anatomical  Tubercle  or  verruca  necrogenica  —  described  by 
Laennec,  is  merely  a  particular  instance  of  tuberculosis  verrucosa. 
Jt  is  encountered  among  medical  students,  physicians,  dissecting- 
room  attendants  and  nurses;  its  more  rapid  course  is  undoubtedly 
explained  by  mixed  infect  ion.  As  early  as  the  day  following  the 
local  infection,  through  a  puncture  or  contaminated  erosion,  a 
painful  erythema  makes  its  appearance,  followed  by  the  formation 
of  an  elevated  dermic  pustule.  In  spite  of  application  of  various 
topical  agents,  the  elevation  persists,  becomes  indurated  and  gradu- 
ally extends  through  the  confluence  of  neighboring  small  pustules. 
The  lesion  promptly  assumes  the  appearance  of  a  horny  papilloma 
or  a  hard  tubercle  covered  by  a  crust;  it  is  surrounded  by  a  purplish- 
red  halo;  it  i>  painful  on  pressure.  The  mixed  tuberculous  and 
pyococcic  infection  may  extend  deeply,  reaching  the  lymph  channels 
and  glands  of  the  elbow  and  the  axilla,  causing  suppurative  adenitis 
and  ultimately  a  visceral  tuberculosis. 

Treatment  of  Tuberculosis  Verrucosa. — This  must  be  early,  rapid 
and  energetic.  The  method  of  choice  is  surgical  excision,  when  this 
is  possible.  In  default  of  excision,  excellent  results  are  obtained  by 
thorough  scraping,  under  local  anesthesia,  followed  by  two  or  three 
radiotherapeutic  sessions  during  the  cicatrization.  Z-rays  or  radium 
employed  alone  are  not  to  be  recommended.  Strong  caustic  agents, 
Vienna  paste,  Unna's  white  caustic  paste,  carbonic  acid  snow  or 
superheated  air,  may  also  be  employed  in  certain  cases.  The  cicatrix 
must  always  be  watched,  as  relapses  are  likely  to  occur. 

Fungoid  and  Vegetative  Tuberculosis. — In  addition  to  tuberculosis 
verrucosa  and  lupus  tumidus  or  vegetans,  a  less  common  form  is 
observed,  which  is  entitled  to  the  name  of  fungoid  tuberculosis, 
proposed  by  Riehl  in  1894. 

It  presents  the  appearance,  either  of  a  very  soft,  irregular  and 
[obulated  red  tumor,  or  of  a  flabby,  distinctly  outlined,  mammillated 
and  prominent  patch.  Its  surface  may  be  ulcerated,  crusted  or 
partly  cicatrized. 

It  seems  to  result  sometimes  from  an  exogenous  inoculation,  in 
other  cases  from  an  auto-infection  of  the  skin  derived  from  a  bony, 
articular  or  glandular  focus.  It  is  met  especially  on  the  limbs,  but 
also  on  the  trunk  and  even  on  the  face.  The  differential  diagnosis 
from  mycosis  fungoides,  epithelioma,  sarcoma,  blastomycosis,  sporo- 
trichosis etc.,  may  present  serious  difficulties,  but  these  can  be 
overcome  by  the  histological  examination,  bacteriological  findings 
and  animal  inoculation. 

The  following  may  be  considered  as  varieties  of  the  above  form: 
Tuberculosis  frambcesiformis  composed  of  large,  soft  and  extensive 
papillomatous  patches,  occupying  especially  the  perigenital  regions; 
it  was  described  by  Doutrelepont,  Wickham,  Hallopeau,  Jessner, 


TUBERCULOSIS 


553 


etc.;  also  the  tuberculosis  fungosa  serpiginosa  of  Jadassohn;  further- 
more, certain  tuberculous  lymphangitides  (fungoid  lymphangitic 
tuberculosis)  studied  by  Bazin,  A.  Fournier,  Morel  Lavallee,  et  al. 
In  the  last-named  variety,  which  closely  resembles  the  lymphan- 
gitic form  of  sporotrichosis  (Fig.  180),  a  series  of  lesions  are  found 
arranged  in  succession  along  the  course  of  lymphatic  vessels  coming 
from  a  tuberculous  focus;  these  lesions  may  be  fungoid  or  in  other 
cases  gummous  or  verrucous;  sometimes  a  subcutaneous,  nodular 
strand  connects  the  various  foci  with  each  other.  Hallopeau  and 
Goupil  described  a  lymphangiectasia  variety,  in  which  the  tuber- 
culous infiltration  is  complicated  by  lymphatic  varicosities;  it  may 
lead  to  secondary  elephantiasis. 

The  treatment  of  the  fungoid  tuberculoses  must  consist  in  scraping 
and  cauterization.  Radiotherapy  may  render  valuable  accessory 
services. 


Fig.  168. — Lupus  vulgaris  (agminatus,  tumidus,  non-exedens)  with  central  sclerosis 
and  centrifugal  extension. 


Lupus  Vulgaris. — Lupus — lupus  vulgaris,  tuberculosis  luposa, 
Willan's  lupus — owes  its  traditional  name  to  the  ulcerative,  gnaw- 
ing, devouring  tendency  frequently  assumed  by  it.  It  represents 
the  most  common  as  well  as  the  most  polymorphous  and  most 
obstinate  form  of  all  cutaneous  tuberculoses. 

Lupus  vulgaris  is  characterized  by  its  eruptive  lesion,  the  lupus 
tubercle  or  lupoma  (page  256). 

It  is  situated,  as  previously  stated,  on  the  face  and  neck  in  the 
great  majority  of  the  cases,  especially  at  the  nose  or  on  the  cheeks; 
more  rarely  on  the  limbs  or  on  the  trunk. 

Varieties. — Lupus  may  assume  extremely  varied  appearances. 
Such  a  large  number  of  varieties  have  been  described  by  authors 


554  INFECTIOUS  BACILLARY  DERMATOSES 

that  one  is  often  at  a  loss  as  to  where  to  group  a  given  case.  Famili- 
arity with  at  least  the  principal  forms  seems  essential. 

Three  types  of  lupus  are  distinguished  according  to  the  distribu- 
tion of  the  lupus  tubercles: 

Lit  pits  disseminatus,  in  which  isolated  or  sometimes  very  numer- 
ous ] lipomas  are  spread  over  one  or  more  regions  of  the  body;  it 
usually  occurs  as  a  sequel  of  infectious  diseases,  especially  measles; 
it  closely  resembles  cutaneous  sarcoid  or  lupoid. 

Lupus  agminatus  is  the  most  common  form;  the  grouped  tubercles 
become  confluent  in  the  center  of  the  patch  as  a  disk  or  plaque  and 
are  scattered  in  the  circumference  (Fig.  168). 

l/upus  diffusus  or  confluens  consists  of  an  often  prominent,  soft, 
nodular  patch,  of  a  purplish,  yellowish  or  brownish-red  color,  with 
rounded,  oval  or  irregular  contours;  the  lupus  tubercles  are  confluent 
and  indistinguishable. 

The  degree  of  prominence  of  the  lupus  permits  a  differentiation 
between  the  following  forms: 

Lupus  Planus. — This  comprises  numerous  varieties,  macular, 
squamous,  psoriatiform,  erythematoid  and  colloid,  which  are  suffi- 
ciently characterized  by  their  designation.  Lupus  planus  is 
usually  of  the  agminated  type. 

Lupus  Tumidus  or  Lupus  Elevatus. — This  form,  which  is  more 
common  than  the  preceding,  likewise  presents  varieties:  colloid, 
myxomatous,  etc. 

Lupus  Hypertrophicus. — An  angiomatous  variety  has  been 
described;  a  papillomatous  variety  which  practically  blends  with 
tuberculosis  verrucosa;  and  an  elephantiastic  variety  which  affects 
the  limbs  especially. 

The  configuration  of  a  lupus  patch  is  of  interest  only  in  so  far  as 
it  is  connected  with  the  course  of  the  affection.  Discoid,  corymbi- 
form,  marginate,  circinate,  centrifugal,  serpiginous,  linear,  annular 
and  other  configurations  have  been  described. 

The  developmental  tendency  of  a  given  lupus  is  the  most  impor- 
tant of  all  its  features.  Raver  and  Devergie  already  recognized 
the  existence  of  two  great  classes  from  this  point  of  view. 

1.  Lupus  nou-exedens,  which  does  not  ulcerate  and  manifests 
itself  in  type,  form  and  configuration  under  one  of  the  numerous 
varieties  enumerated  above.  It  grows  slowly,  continuously  or 
intermittently. 

It  not  infrequently  becomes  transformed  into  a  cicatrix  at  its 
center;  but  a  recurrent  growth  of  the  lupomas  in  the  sclerotic 
tissue  is  far  from  uncommon.  When  spontaneous  total  cicatriza- 
tion occurs,  as  in  lupus  planus  and  even  in  lupus  tumidus,  the 
condition  is  described  as  scleroticus  or  resolutus. 

The  erythematoid  variety  of  lupus  planus,  also  known  as  ery- 


TUBERCULOSIS  555 

themato-tuberculous  lupus  of  Vidal  and  Leloir,  was  considered  by 
the  last-named  author  as  a  combination  of  Willan's  lupus  with  the 
lupus  erythematodes  of  Cazenave.  It  gives  rise  to  frequent  errors 
in  diagnosis.  This  is  really  a  superficial  tuberculous  lupus,  as 
properly  recognized  by  Dubreuilh;  the  lupomata  are  small,  sub- 
epidermic,  sometimes  confluent  and  not  readily  perceptible  to  the 
unaided  eye;  but  they  are  distinctly  revealed  on  biopsy.  In  this 
variety  of  lupus,  which  may  invade  the  nose  and  the  cheeks  in  the 
form  of  a  butterfly,  there  is  a  pronounced  tendency  to  spontaneous 
cure;  it  is  of  the  resolutive  type. 

A  lupus  non-exedens  may  at  any  moment  of  its  course  become 
erosive,  ulcerative  and  even  mutilating;  so  that  there  is  no  essential 
difference  between  this  class  of  lupus  and  the  following: 

2.  Lupus  exedens,  or  primarily  ulcerative  lupus,  often  takes  a 
violent  and  rapid  course;  its  exuberant  proliferation,  its  active 
growth,  its  relatively  rapid  extension  and  the  final  partial  disin- 
tegration undergone  by  it,  lead  to  early  destruction  and  mutilation. 
It  assumes  one  of  the  following  clinical  forms : 

Pustular  lupus  consists  of  soft  elevations  the  size  of  a  cherry 
pit,  which  have  a  tendency  to  become  confluent  and  which  in  less 
than  a  month  open  like  abscesses. 

Ulcerative  vegetative  lupus  is  composed  of  soft  fungoid  infiltra- 
tions, producing  for  instance  the  appearance  of  a  tomato,  into  which 
sharp  instruments  will  cut  as  into  butter;  the  ulceration  which 
results  from  the  breaking-down  of  the  newformation,  leads  to  fear- 
ful mutilations  of  the  nose,  the  lips,  the  velum  of  the  palate,  the 
eyelids,  etc.  It  is  described  as  lupus  vorax  or  lupus  phagedenicus 
when  its  course  is  especially  rapid. 

Serpiginous  tuberculo-ulcerative  lupus,  which  may  precede  or 
follow  a  lupus  non-exedens,  is  seen  on  the  trunk  and  the  limbs  even 
more  often  than  on  the  face  and,  like  erythematoid  lupus,  prefer- 
ably in  aged  individuals;  it  consists  of  a  central  cicatrix  bordered 
by  large  pustular  crusted,  sometimes  rupioid,  lupus  tubercles.  It 
closely  resembles  the  ulcerative-serpiginous  syphilides  and  although 
its  course  is  slower  it  may  periodically  progress  very  rapidly. 

The  varieties  of  lupus  most  commonly  met  with  are,  briefly: 
lupus  planus  agminatus,  with  a  tendency  toward  central  cicatriza- 
tion; lupus  tumidus  agminatus  in  patches,  level  or  protuberant; 
and  tuberculo-crusted  or  tuberculo-ulcerative  lupus  serpiginosus . 

It  is  extremely  common  for  a  lupus  which  has  not  been  treated 
or  even  dressed  to  present  itself  covered  with  yellowish  or  brown- 
ish crusts;  in  such  cases  it  is  impossible  at  the  first  examination 
and  before  it  has  been  cleansed  to  determine  the  variety  to  which 
it  belongs.  The  formation  of  the  crusts  and  of  the  erosions  con- 
cealed by  them  is  undoubtedly  referable  in  part  to  a  pyodermic 


>56 


INFECTIOUS   BACILLARY   DER  WATOSES 


complication.  Lupus  which  is  thus  disfigured  is  ordinarily  called 
impetiginous  lupus  I  Fig.   169). 

All  these  morphological  varieties  really  possess  only  a  didactic 
and  diagnostic  value.  Lupus  vulgaris  is  single  in  character  and 
may  very  readily  assume  a  variable  appearance  and  behavior  at 
different   points  or  different   times. 

Etiology.  Topography.  Lupus  may  appear  at  any  age,  but  in 
more  than  one-half  of  the  cases  it  manifests  itself  before  the  fifteenth 
and  rarely  after  the  thirtieth  year.  It  is  more  common  in  the 
female  sex  and  in  Northern  countries.     A  certain  family  predispo- 


Fig  101). — Lupus  Lmpetiginosus  with  multiple  foci,  showing  tin-  points  of  inocula- 
tion of  the  skin.  The  infection  probably  occurred  through  the  nostrils  and  the  nasal 
fossa',  reaching  the  nose  and  the  cheek  directly;  attaining  the  internal  angle  of  the 
eye  through  the  lachrymal  duct;  the  submaxillary  region  by  way  of  the  glands;  a 
U-w  of  the  latter  were  extirpated,  as  indicated  by  the  keloid  cicatrix  under  the  ear; 
the  other  glands  suppurated  and  opened  on  the  skin. 


sit  ion  seems  to  play  a  part;  A.  Ollivier  mentions  the  ease  of  a  family 
of  five  children,  four  of  whom  had  lupus.  Very  frequently  an 
apparent  tuberculosis  is  found  in  the  ascendants  or  collaterals; 
however,  as  pointed  out  by  Besnier,  consumptives  do  not  acquire 
lupus,  whereas  lupus  patients  very  frequently  develop  pulmonary 
tuberculosis. 

[All  forms  of  lupus  and  especially  the  highly  destructive  forms 
are  rare  in  America  as  contracted  with  their  frequency  in  European 
countries.  The  high  daily  average  of  sunlight  throughout  North 
America  may  possibly  play  a  role  in  this  relative  freedom,  hut  on 


TUBERCULOSIS  557 

the  other  hand,  lupus  is  common  in  sunny  Italy.  It  seems  more 
probable  in  view  of  the  fact  that  lupus  is  preeminently  a  disease  of 
the  poor,  that  the  better  nourishment  of  the  poorer  classes  in 
America  is  the  important  factor.] 

Lupus  attacks  principally,  although  not  exclusively,  individuals 
of  a  scrofulous  habitus,  with  thick,  soft  flesh,  a  pale  or  florid  com- 
plexion, swollen  nose  and  lips,  acro-asphyxia,  frost-bite,  chronic- 
glandular  enlargements  and  a  readily  vulnerable  skin;  in  scrofulous 
women,  the  ear-lobes  are  often  cut  by  the  wearing  of  ear-rings. 
This  classical  scrofula  is  now  known  to  correspond,  not  to  a  soil 
merely  susceptible  to  the  bacillus,  but  rather  to  an  accomplished 
but  attenuated  and  latent  bacillary  infection.  Lupus  accordingly 
seems  to  result  from  a  local  superinfection  of  autogenous  or  exog- 
enous origin,  in  an  individual  in  a  state  of  allergy. 

In  the  tissues  of  lupus,  bacilli  are  very  rare  and  dozens  of  sections 
must  be  examined  before  one  is  found.  They  have  been  assumed 
to  be  of  a  special  strain  or  attenuated  virulence,  which  would  agree 
with  the  slow  course  of  lupus.  According  to  recent  findings,  the 
condition  is  more  frequently  due  to  the  human  than  to  the  bovine 
bacillus;  as  to  its  virulence,  the  following  statements  can  be  made: 
Inoculation  of  lupus  tissue,  correctly  grafted  into  the  guinea-pig's 
peritoneum,  gives  rise,  as  a  rule,  to  ordinary  tuberculosis,  trans- 
missible to  a  series  of  animals;  however,  in  my  experience,  the 
inoculation  is  unsuccessful  in  over  one-third  of  the  cases.  Pau- 
trier,  who  inoculated  neighboring  fragments  of  the  same  lupus  into 
guinea-pigs,  obtained,  in  the  same  series,  sometimes  positive  and 
sometimes  negative  results.  Whatever  may  be  the  explanation  of 
these  cases,  it  seems  to  me  that  in  combination  with  the  clinical 
data,  they  justify  the  interpretation  of  lupus  as  a  relatively  slightly 
virulent  form  of  cutaneous  tuberculosis  and  even  as  an  intermediate 
pathological  type  between  the  true  cutaneous  tuberculoses  and  the 
tuberculides. 

The  portal  of  entry  of  the  local  infection  which  causes  lupus  is 
external  or  internal.  The  possibility  of  its  resulting  from  an 
accidental  inoculation  of  exogenous  origin  is  attested  by  authentic 
cases  in  which  a  lupus  has  been  seen  to  supervene  in  an  apparently 
healthy  person,  following  upon  a  wound,  perforation  of  the  ear 
lobules,  vaccination,  etc.  Perhaps  the  ordinary  impetigo  of  chil- 
dren may  serve  as  an  avenue  of  entrance.  The  frequency  of  lupus 
on  the  nose  or  in  its  vicinity  is  accounted  for  by  the  infection  of 
the  nasal  fossae  through  the  dust  inhaled  in  respiration  or  by  contact 
with  the  fingers.  As  a  matter  of  fact,  four-fifths  of  lupus  lesions 
are  situated  on  the  face  (Fig.  169). 

On  the  other  hand,  the  origin  of  the  superinfection  may  be  autog- 
enous and  the  inoculation  of  the  skin  take  place  from  within  out- 


558  INFECTIOUS  BACILLARY  DERMATOSES 

ward  as  in  case  of  lupus  following  upon  broken-down  glands,  of 
common  occurrence  in  the  neck;  or  upon  tuberculous  osteitis,  as  seen 
on  the  limbs.  Lupus  of  the  cheek  may  be  due  to  a  tuberculous 
lymphangitis  derived  from  the  nasal  fossse. 

Cases  in  which  the  bacillus  arrives  from  some  internal  focus  by 
way  of  the  vascular  system  are  more  numerous  than  is  usually 
assumed.  Disseminated  lupus  lesions  are  evidently  produced  by 
this  means,  favored  especially  by  a  temporary  loss  of  body  resist- 
ance under  the  influence  of  measles,  grippe,  pregnancy,  etc. 

On  the  genital  organs,  lupus  is  rare;  in  women,  it  has  been  con- 
fused with  esthiomene.  At  the  circumference  of  the  anus,  lupus  is 
often  combined  with  papillomatous  tuberculosis  or  tuberculous  ulcer- 
ations and  results  from  an  auto-inoculation  with  bacilli  contained 
in  the  dejecta. 

The  palmar  and  plantar  regions  and,  to  a  certain  degree,  the 
trunk  but  very  particularly  the  scalp,  are  endowed  with  a  relative 
immunity  toward  lupus. 

Lupus  of  the  mucous  membranes  is  encountered  in  one-third  of 
the  cases,  but  must  be  looked  for.  I  have  pointed  out  that  the 
initial  focus  is  frequently  nasal.  Often  soft  elevations  are  observed 
on  the  anterior  portion  of  the  septum  leading  to  perforation  of  the 
latter.  From  here,  propagation  takes  place  to  the  eyelids  through 
the  lachrymal  passages,  but  the  conjunctiva  usually  escapes;  or 
to  the  palate  and  gums,  through  the  anterior  palatine  foramen, 
and  more  frequently,  to  the  velum  of  the  palate  and  to  the  pharynx. 

In  the  throat,  in  the  mouth  and  the  larynx,  lupus  usually  assumes 
the  appearance  of  a  pinkish  mammillated  surface  interspersed  with 
ulcerations;  on  the  gums,  that  of  a  crop  of  soft  red  fleshy  prolifera- 
tions; on  the  tongue  it  is  very  rare  and  almost  invariably  assumes 
a  papillomatous  form,  although  I  have  seen  a  lupus  ulcer  of  the 
tongue. 

In  a  general  way,  although  lupus  of  the  mucous  membranes 
belongs  to  different  varieties  and  although  no  lupomata  of  a  barley- 
sugar  appearance  are  here  demonstrable,  its  course  and  the  usual 
coexistence  of  lupus  of  the  skin  serve  to  facilitate  its  diagnosis. 

Course  and  Complications. — The  long  duration  of  lupus  and  its 
rebellious  character  are  its  most  essential  features.  Lupus  per- 
sisting for  ten  or  twenty  years  is  very  common.  Feulard  reported  a 
case  of  sixty-eight  years'  standing. 

Its  ulcerative  forms,  but  also  up  to  a  certain  point  those  with  a 
tendency  to  cicatrization,  lead  to  deformities  and  truly  hideous 
mutilations;  ectropion,  complete  destruction  of  the  nose  with 
stricture  or  even  atresia  of  the  nostrils,  buccal  atresia,  vicious  and 
keloid  cicatrices  and  transformation  of  the  extremities  into  mis- 
shapen stumps  (Fig.  170)  are  not  uncommon. 


TUBERCULOSIS  559 

The  course  of  lupus  may  be  interrupted  by  congestive,  edematous 
or  suppurative  exacerbations. 

Recurrent  lymphangitis  seems  to  play  a  part  in  the  elephanti- 
astic  form.  Erysipelas ,  considered  as  favorable  by  some  authors, 
appeared  rather  injurious  in  the  majority  of  cases.  Corresponding 
glandular  enlargement  or  adenopathy  is  rather  common  although 
not  constant. 

Pulmonary  and  visceral  tuberculosis  is  responsible  for  a  large 
number  of  deaths  among  lupus  patients,  although  it  usually  takes 
a  slow  and  protracted  course  in  these  cases.  Many  patients 
affected  with  lupus  otherwise  enjoy  excellent  health.  I  have  seen 
several  who  were  married  and  had  a  healthy  progeny. 


Fig.  170. — Lupus  mutilans  of  the  hand. 

Epithelioma  is  a  formidable  complication  of  lupus,  on  account 
of  its  rapidly  invasive  course.  Its  frequency  has  been  estimated 
at  4  per  cent,  of  the  cases.  The  onset  of  cancer  is  recognized  by  the 
changed  appearance  of  an  area  of  the  lupus  eruption,  where  a 
hard  painful  proliferation  arises  and  promptly  ulcerates  or  under- 
goes partial  necrosis;  biopsy  is  often  required  to  confirm  the  diag- 
nosis. 

Tertiary  or  congenital  syphilis  has  been  charged  with  creating  a 
predisposition  to  lupus;  a  possible  association  has  even  been  sus- 
pected on  the  basis  of  the  sometimes  very  favorable  although 
incomplete  effects  of  mercurial  treatment  in  some  cases  of  lupus. 

Diagnosis. — The  differentiation  of  lupus  from  tubercular 
or  tuberculo-ulcerative  tertiary  syphilides  is  most  frequently 
demanded.     The   course   and   the   age   of  the   lesions   sometimes 


560  INFECTIOUS  BACILLARY  DERMATOSES 

furnish  presumptive  evidence;  actually,  leaving  aside  lupus  exe- 
dens,  it  may  be  stated  that  lupus  requires  years  to  accomplish 
what  syphilis  will  do  in  a  few  weeks  or  months.  The  softness, 
the  yellow  translucid  color  of  the  lupus  nodule  and  its  renewed 
growth  in  the  cicatrix,  are  characteristic  of  lupus.  However, 
certain  syphilides  are  "lupoid"  to  such  a  degree,  even  on  histo- 
logical examination,  that  the  question  can  be  settled  only  by  means 
of  the  Wassermann  reaction  and  guinea-pig  inoculation;  the  local 
tuberculin  reaction  also  possesses  a  real  value. 

The  color,  the  opacity,  the  elastic  consistence  and  the  anesthesia 
of  the  tubercles  of  leprosy  are  sufficiently  characteristic  to  guard 
against  error;  all  doubts  will  be  removed  by  a  general  examination 
of  the  patient. 

The  confusion  of  lupus  with  eczema,  impetigo  or  psoriasis  is 
inexcusable,  although  it  may  assume  the  objective  appearance  of 
an  impetiginous  or  psoriatiform  eruption. 

The  lupoid  sycosis  of  Brocq  affects  only  the  hairy  regions,  is 
distinctly  cicatricial  in  the  center  and  bordered  by  suppurating 
folliculitis. 

The  differentiation  may  prove  very  difficult  between  lupus  dis- 
seminata and  the  sarcoid  of  Boeck,  which  I  have  described  under 
the  name  of  disseminated  miliary  lupoid;  histological  examina- 
tion and  guinea-pig  inoculation  furnish  the  only  reliable  criteria. 
The  boundaries  between  various  forms  of  lupus  and  tuberculosis 
verrucosa,  or  tuberculosis  fungoides  and  its  varieties,  are  indefi- 
nite, so  that  well-informed  dermatologists  will  group  under  one  of 
these  headings  cases  which  by  others  are  considered  as  lupus; 
at  any  rate,  these  dermatoses  are  of  the  same  nature. 

What  I  shall  have  to  say  further  on  in  regard  to  lupus  erythema- 
todes,  actinomycosis,  the  blastomycosis,  the  leishmanioses,  etc., 
will  probably  suffice  to  permit  the  diagnosis  of  these  affections. 

The  tuberculin  test  with  Koch's  tuberculin  A,  in  subcutaneous 
injection,  when  it  produces  a  positive  local  reaction  to  a  minimum 
dose  possesses  real  value  not  only  for  the  recognition  of  lupus  but 
for  the  determination  of  its  clinically  undemonstrable  extent.  The 
cuti-reaction  of  von  Pirquet  with  crude  tuberculin  or  Morn's 
procedure  which  consists  in  the  comparative  rubbing  of  a  small 
lupus  surface  and  a  surface  of  healthy  skin  with  tuberculin  incor- 
porated in  lanolin,  equal  parts,  may  also  be  utilized. 

Lupus  of  the  mucous  membranes  may  simulate  very  different 
affections;  usually  the  coexistence  of  lupus  of  the  skin  is  of  great 
help.  In  primary  cases,  the  differential  diagnosis  from  focal 
syphilomata  and  from  papillary  epithelioma  is  extremely  difficult; 
the  differential  features  may  be  insufficient  and  biopsy  as  well  as 
serodiagnosis  become  indispensable. 


TUBERCULOSIS  561 

Treatment. — I  shall  refrain  from  entering  into  details  on  this 
inexhaustible  topic,  restricting  myself  to  practical  suggestions. 
It  is  evident  that  the  seat,  the  extent  of  the  lesions,  the  age,  the 
social  condition  and  the  general  health  of  the  patient  must  influ- 
ence the  choice  of  the  therapeutic  method. 

When-  a  lupus  is  operable  without  mutilation,  the  preference 
must  be  accorded  to  surgical  removal,  with  or  without  autoplas- 
tics; the  tuberculin  test  should  first  be  carried  out  in  order  to 
recognize  its  actual  limits,  following  the  advice  of  Neisser  and  Kling- 
miiller.  Extirpation  should  accordingly  be  the  method  of  choice 
in  lupus  of  the  limbs,  the  trunk,  the  neck,  unless  it  is  too  extensive. 

Curettage,  if  necessary  under  anesthesia,  may  yield  rapid  but 
unreliable  results,  only  mediocre  from  the  cosmetic  point  of  view; 
in  all  cases,  this  treatment  should  be  combined  with  cauterization 
by  the  actual  cautery  or  caustic  agents,  carefully  watching  the 
cicatrization,  during  which  radiotherapy  may  usefully  be  employed. 

Total  destruction  through  cauterization  (thermocautery,  galvano- 
cautery,  superheated  air)  or  through  chemical  caustics  (such  as 
trichloride  of  antimony,  trichloracetic  and  hydrochloric  acids,  etc.) 
is  open  to  the  same  objections. 

Abroad,  pyrogallol  is  freely  used  as  a  salve  (from  5  to  20  per 
cent.)  but  it  is  very  painful;  the  green  salve  of  Unna  (see  Thera- 
peutic Notes)  seemed  preferable  to  me. 

Most  frequently,  graduated  progressive  methods  together  with 
physical  agents  should  be  resorted  to,  thereby  stimulating  or  favor- 
ing the  sclerotic  process  adopted  by  nature  in  cases  of  spontaneous 
cure. 

Crossed  linear  scarifications  would  constitute  an  excellent  cura- 
tive procedure,  in  view  of  the  qualities  of  the  resulting  cicatrix,  but 
for  the  often  considerable  and  even  endless  number  of  sessions 
required  for  this  treatment.  Nevertheless,  scarifications  are  impera- 
tive in  case  of  vegetative  lupus  or  lupus  vorax,  which  they  control 
with  remarkable  rapidity;  in  lupus  of  the  orifices  of  the  face;  and 
for  the  correction  of  lupus  cicatrices  with  a  persistent  crop  of 
tubercles. 

Ignipuncture  with  the  galvanocautery  does  not  aim  at  the 
total  destruction  of  the  lupus,  but  like  scarification  tends  to  pro- 
duce centers  of  cicatrization  which,  multiplied  by  later  sessions, 
lead  to  confluence.  This  is  a  most  valuable  procedure  for  the 
reason  that  it  is  inexpensive,  more  rapid  than  scarification,  easily 
applicable,  particularly  adapted  to  cases  of  lupus  already  modified 
by  previous  treatment  and  especially  unrivalled  in  lupus  of  the 
mucous  membranes. 

As  adjuvants  of  the  preceding  methods,  or  even  sometimes 
exclusively,  according  to  some  authors,  medicinal  topical   agents 


662  INFECTIOUS  BACILLARY  DERMATOSES 

have  been  recommended  and  may  prove  highly  advantageous;  I 
shall  quote  only  potassium  permanganate  in  strong  solution  or 
even  in  substance,  pyrogallol,  resorcin  and  especially  mercurials  in 
the  form  of  plasters. 

The  introduction  of  new  physical  methods  has  partly  transformed 
and  certainly  improved  the  traditional  therapy  of  lupus. 

The  phototherapy  of  FinseD  undoubtedly  yields  the  best  cos- 
metic results,  moreover  without  pain;  on  the  other  hand,  it  is 
open  to  serious  objections  on  account  of  the  considerable  number 
of  sessions  required  (200  to  300  for  a  lupus  of  moderate  extent), 
the  very  high  cost  of  the  apparatus  and  the  sessions,  as  well  as 
the  failures,  the  proportion  of  which  is  not  inconsiderable.  The 
mercury  vapor  quartz  lamp  is  more  convenient  and  less  expensive. 

Radiotherapy  and  radiumtherapy  have  not  entirely  justified 
the  expectations  placed  upon  them.  Their  indication  and  their 
mode  of  employment  in  lupus  are  still  a  matter  of  controversy. 
However,  the  majority  of  authors  are  agreed  in  the  repudiation 
of  destructive  doses  which  involve  the  risk  of  sometimes  tardy  but 
always  formidable  radiodermatitis.  Injudicious  repetition  of  the 
sessions  involves  the  same  dangers.  In  moderate  doses,  the  radia- 
tions are  very  efficient  in  fungoid  or  papillomatous  lupus  and  in 
superficially  ulcerated  lupus  lesions.  But  the  x-rays  are  especi- 
ally to  be  recommended  as  adjuvants  and  I  may  say  that  at  the 
present  writing,  galvanopuncture  or  periodical  scarifications  fol- 
lowed by  radiotherapy  in  cautious  dosage,  seem  to  constitute  the 
best  treatment  of  lupus  not  amenable  to  surgical  extirpation. 
Radium  should  be  accorded  the  preference  in  cases  of  lupus  of  the 
mucous  membranes  or  lesions  difficult  of  access. 

Internal  treatment  alone  must  never  be  relied  on  for  the  cure  of  a 
lupus,  but  there  is  often  reason  for  and  marked  benefit  to  be  expected 
from  medication  with  calcium,  arsenic,  cod-liver  oil  and  iodides;  as 
well  as  from  a  sojourn  in  suitable  watering-places  by  the  seaside 
or  on  high  mountains.  This  climatotherapy  may  be  combined  with 
heliotherapy,  which  is  very  beneficial  when  properly  employed. 

Among  the  various  hypodermic  injections  which  have  been 
advocated,  notably  cacodylates,  cantheridin,  nuclein,  thiosinamin, 
etc.,  in  my  opinion  calomel  injections  are  the  only  ones  which  can 
sometimes  be  recommended.  When  applied  as  in  the  treatment 
of  syphilis,  they  are  capable  of  producing  remarkable  improve- 
ment, but  are  found  to  be  very  unreliable;  on  the  other  hand, 
systematic  injections,  in  gradually  increased  doses,  of  Koch's  tuber- 
culin A,  which  I  have  resumed  after  many  other  trials,  have  some- 
times yielded  remarkably  rapid  favorable  results  in  my  experience; 
great  caution  is  required  in  their  use. 

The  treatment  of  lupus  needs  insight,  considerable  patience  and 


TUBERCULOSIS  563 

skill  in  the  variation  and  combination  of  the  methods  best  adapted 
to  the  individual  case  as  well  as  indefatigable  perseverance  in  the 
management  of  partial  relapses.  A  cure  cannot  be  considered  as 
practically  certain  until  several  years  have  elapsed  after  the  dis- 
appearance of  the  visible  lesions. 

Tuberculides. — Since  my  suggestion  in  1896  a  number  of  appar- 
ently very  dissimilar  dermatoses  have  been  grouped  under  this 
heading,  whose  relations  with  tuberculosis  are  proved  by  the  follow- 
ing features. 

The  tuberculides  themselves  are  frequently  associated  in  the 
same  individual  and  very  often  coexistent  with  glandular,  bony, 
serous,  visceral  or  cutaneous  tuberculous  manifestations;  or  the 
patients  have  a  tuberculous  history,  or  are  found  to  be  tuberculous 
later  on. 

The  histological  structure  of  the  tuberculides  is  sometimes 
typically  tubercular  and  identical  with  that  of  the  most  positive 
tuberculoses;  in  other  cases  it  is  non-tubercular,  inflammatory  and 
necrotic;  but  this  is  now  known  to  be  the  case  even  in  certain 
undoubtedly  bacillary  tuberculoses. 

As  a  rule,  no  Koch's  bacilli  are  found  in  the  tuberculides;  how- 
ever, several  authors  report  their  discovery  by  means  of  the 
improved  methods  of  Much-Gram,  with  antiformin,  etc.  Inocu- 
lation of  their  tissue  into  guinea-pigs  is  usually  negative;  but 
exceptions  to  this  rule  have  occurred,  diminishing  the  demon- 
strative value  of  the  usual  negative  findings.  Furthermore,  it  is 
noteworthy  that  Gougerot  experimentally  produced  analogous 
lesions,  which  he  regards  as  identical  with  tuberculides,  by  rubbing 
pure  cultures  of  Koch's  bacilli  on  the  shaved  skin  of  the  guinea- 

Pig- 

The  tuberculin  test  is  often,  but  not  invariably,  positive  in  the 
tuberculides. 

From  the  point  of  view  of  their  clinical  course,  the  tuberculides 
in  general  are  distinguished  from  the  cutaneous  tuberculoses  by 
their  usual  occurrence  in  a  disseminated  form,  which  is  less  com- 
mon in  the  latter;  and  moreover  by  their  marked  tendency  to 
spontaneous  cure. 

They  appear  in  successive  crops,  without  fever,  without  dis- 
turbance of  the  general  condition;  they  often  have  a  symmetrical 
distribution  and  a  variable  but  rather  prolonged  duration.  The 
various  forms  have  a  marked  predilection  for  certain  periods  of  life 
and  for  certain  regions  which  are  predominantly  affected. 

Clinical  Forms. — As  nearly  all  the  forms  of  tuberculides  were 
observed  and  described  before  their  real  nature  was  suspected, 
the  names  they  bear  are  based  on  their  morphological  appearance, 
so  that  their  nomenclature  is  a  regular  Joseph's  coat.     To  bring 


564  INFECTIOUS  BACILLARY  DERMATOSES 

some  order  into  this  disorder,  I  recommend  the  following  classifi- 
cation : 

A.  Cutaneous  Tuberculides. — The  seat  of  the  lesions  is  dermo- 
epidermic  in  the  following  forms: 

1.  Lichenoid  tulwrculides  (lichen  scrofulosorum  and  lichen  nitidus 
— these  forms  have  already  been  sufficiently  described  (pp.  146, 
138).  I  have  seen  also  a  few  rare  cases  which  simulated  patches 
of  lichen  planus. 

'2.  Papulonecrotic  tuberculides  (folliclis  and  acnitis  of  Barthelemy). 

3.  Acneiform  tuberculides  (acne  cachecticorum  of  Hebra) — this  is 
simply  a  variety  of  the  preceding  form. 

4.  Lupoid  tuberculides  (benign  sarcoids  or  lupoids  of  Boeck 
(p.  259). 

5.  Erythemato-atrophic  tuberculides  (lupus  erythematodes  of  Caze- 
nave  and  certain  atrophodermas). 

6.  Erythematous  tuberculides  (lupus  erythematodes  exanthema- 
ticus). 

B.  Hypodermic  Tuberculides. — Three  principal  types  have  been 
described:  the  erythema  induratum  of  Bazin,  the  subcutaneous 
sarcoids  of  Parier-Roussy  and  the  disseminated  nodular  sarcoids; 
in  all  probability  these  are  simply  varieties  of  the  same  species 
(p.  272).  Certain  scrofulous  gummas  of  attenuated  virulence 
(p.  268)  and  a  few  atypical  tuberculous  ulcers  (p.  291)  are 
evidently  related  to  this  group. 

C.  Doubtful  Tuberculides. — It  is  necessary  to  point  out  in  this 
connection  a  certain  number  of  affections  whose  relations  with 
tuberculosis  are  emphasized  by  some  authors  but  denied  by  others; 
these  relations  are  problematical  or  perhaps  indirect.  Such  con- 
ditions are: 

Certain  forms  of  frost-bite  (pernio  tuberculides)  (p.  34). 
Piti/riasis  rubra  of  Hebra-Jadassohn  (erythrodermic  tuberculide) 

<P-  li8)/ 
Certain    forms    of    parapsoriasis    (parapsoriatic    tuberculides?) 

(p.  111). 

Pityriasis  rubra  pilaris  (erythrodermic  perifollicular  tuberculide?) 
(p.  399). 

Perhaps  certain  cases  of  eczema  folliculorum  of  Malcolm  Morris 
and  a  few  other  authors  (eczematoid  tuberculides?)  (p.   396). 

Perhaps  also  angiokeratoma  (angiokeratotic  tuberculides)  (p. 
695). 

This  enumeration,  lengthy  as  it  is,  does  not  exhaust  the  subject. 
As  a  matter  of  fact,  only  the  relatively  common  and  fairly  well- 
established  clinical  types  have  so  far  been  described  under  a  special 
name.  There  exist  more  rare  types  as  well  as  some  with  mixed 
features  and  transition  forms  as  yet  unclassifiable.     I  have  seen 


TUBERCULOSIS  565 

cases,  for  example,  which  might  have  been  indifferently  diagnosed 
as  lupus  pernio  or  folliclis  or  lupus  erythematodes;  all  that  could 
be  stated  was  that  the  case  was  one  of  tuberculide.  One  would 
naturally  hesitate  to  lay  down  exact  rules  for  unique  cases  or  for 
transition  forms  which  are  of  exceptional  occurrence. 

Nature  and  Pathogenesis. — According  to  their  mental  proclivities, 
authors  have  conceived  a  different  and  even  contradictory  inter- 
pretation of  the  nature  of  these  dermatoses.  In  the  opinion  of 
some,  their  relations  with  tuberculosis  were  extremely  doubtful. 
Tuberculosis,  they  said,  is  a  disease  so  widely  distributed  that  its 
presence  in  a  patient  or  his  environment  is  irrelevant.  The  course 
of  the  tuberculides,  the  absence  of  really  scientific  proofs  of  their 
bacillary  origin,  justify  neither  their  arbitrary  grouping  with  the 
legitimate  tuberculoses  nor  the  assumption  of  their  kinship  with 
them. 

Others,  on  the  contrary,  regarded  the  tuberculous  nature  of  these 
affections  as  so  unquestionable  that  it  was  actually  proposed  to 
abandon  the  provisional  term  of  tuberculides  and  to  incorporate 
this  group  among  the  cutaneous  tuberculoses,  of  which  they  were  sup- 
posed to  represent  still  more  attenuated  types  than  lupus  vulgaris, 
for  example.  The  dissemination  and  customary  symmetry  of  tuber- 
culide eruptions  were  explained  as  due  to  the  virus  having  travelled 
by  the  vascular  route.  With  reference  to  the  attenuated  virulence 
of  the  lesions,  various  interpretations  were  suggested.  The  theory 
of  Hallopeau,  according  to  which  the  tuberculides  are  dependent, 
not  on  the  bacilli  themselves,  but  on  their  soluble  toxins  (toxi- 
tuberculides)  met  with  many  objections.  The  interpretation  of 
Haury  appeared  much  more  probable;  in  his  opinion  the  tubercu- 
lides result  from  embolisms  of  dead  or  attenuated  bacilli,  perhaps 
due  to  the  struggle  they  had  undergone  against  the  defensive  forces 
of  the  organism  in  a  primary  glandular  or  other  infectious  focus 
or  in  the  blood  current.  These  bacilli  arrive  in  the  skin  while  still 
capable  of  exciting  a  temporary  local  reaction  and  even  small 
necrotic  foci;  but  they  succumb  or  disappear  more  or  less  rapidly — 
hence  the  spontaneous  cure  and  non-inoculability  of  the  lesions. 

By  applying  to  the  interpretation  of  the  tuberculides  the  preva- 
lent view  of  tuberculous  infection,  their  pathogenesis  becomes  con- 
siderably clearer.  Tuberculosis  is  an  almost  universal  infection; 
it  heals  very  often  to  the  point  of  becoming  clinically  latent;  but  it 
remains  nevertheless  capable  of  reviving  under  various  influences 
and  of  giving  rise  to  a  discharge  of  bacilli;  it  creates  a  state  of 
relative  immunity  which  manifests  itself  by  the  phenomena  of 
allergy.  It  thus  becomes  intelligible  that  the  cutaneous  manifes- 
tations resulting  from  bacillary  embolisms  may  vary  greatly  in 
form  and  behavior,  according  to  the  degree  of  attenuation  of  the 


566  tNFECTIOUS  BACILLARY  DERMATOSES 

bacilli,  according  to  the  Dumber  of  imported  bacilli,  as  well  as 
according  to  the  degree  and  kind  of  allergy  enjoyed  by  the  indi- 
vidual. But  these  incomplete  data  and  speculations  still  require 
definite  scientific  confirmation. 

Papulonecrotic  Tuberculides.  This  clinical  form  was  first  described 
under  the  name  of  lupus  erythewaforfe*  rfisxcniiiKitiix  (Boeck,  1880), 
then  as  cicatricial  folliculitis  of  the  hairless  part*  (Brocq),  as  fob- 
liclis  and  aortitis  (Barthelemy)  [as  hydradenitis  destruens  suppurativa 
(Pollitzer)],  as  hidrosadenitis  suppurativa  disseminata  (Dubreuilh); 
Kaposi  called  it  acne  telangiectodes. 

It  is  not  very  rare  and  occur-  especially  in  adolescents  and  young 
adults. 

The  eruption,  consisting  of  a  very  variable  number  of  lesions, 
appears  in  successive  crops.  It  occupies  preferably  the  hands  and 
the  fingers,  the  forearms  (Fig.  171),  the  elbows,  the  circumference 
of  the  knees,  the  feet,  the  face,  the  ears  and  not  infrequently  also 
the  trunk. 


Fig.   171. — Papulonecrotic  tuberculides.     In  this  patienl   the  eruption  occurred  on 
t lie*  four  extremities. 

The  typical  lesions  begin  as  a  very  minute  dull-red  elevation, 
which  on  palpation  reveals  a  hard  painless  nodule,  the  size  of  a 
pin-head,  more  or  le>s  deeply  imbedded  in  the  cutis;  in  about  a 
week,  this  nodnle  becomes  raised,  its  surface  turns  livid  and  pur- 
plish, while  an  epidermic  vesico-pnstule  appears  at  its  summit. 
When  this  is  opened  with  a  pin,  only  a  very  small  amount  of  turbid 
serum  escapes,  and  a  sharp-bordered  depression  with  a  grayish 
floor  appears  in  the  cutis.  Left  unopened,  the  lesions  become 
transformed  into  crusts  which  are  not  shed  till  after  two  to  four 
weeks  and  leave  distinct  depressed  cicatrices,  often  pigmented  in 
their  circumference  and  fairly  characteristic.  The  crops  following 
one  another,  the  different  stages  are  observed  simultaneously.  The 
total  duration  is  several  months  or  several  years,  with  a  tendency 
to  seasonal  recurrences. 


TUBERCULOSIS 


567 


With  this  principal  type,  which  may  be  designated  as  folliclis, 
the  following  varieties  are  connected. 

Acnitis  of  Barthelemy  (Fig.  172)  is  seen  in  youthful  or  adult 
individuals,  beginning  and  always  predominating  on  the  face, 
although  sometimes  scattered  over  the  extensor  surface  of  the 
limbs  and  the  genital  organs.  The  lesions  consist  of  hard,  miliary, 
distinctly  circumscribed,  isolated  and  indolent  nodules,  which 
originate  in  the  depth  of  the  cutis,  may  become  absorbed,  but  more 
frequently  suppurate  and  open  on  the  surface,  leaving  a  minute 
cicatrix  behind.  Each  lesion  lasts  about  one  month,  the  eruption 
is  continued  over  several  months  and  is  subject  to  recurrence. 


Fig.  172. — Acnitis  in  a  man  aged  twenty  years. 


Acne  cachecticorum  consists  of  slightly  raised  papulo-vesicular  or 
superficial  pustular  miliary  lesions,  with  a  livid  base,  which  appear 
in  crops,  without  pruritus,  in  children  or  sometimes  in  adolescents 
or  adults;  they  are  situated  principally  on  the  limbs,  to  a  small 
extent  on  the  trunk  and  on  the  face  and  scalp.  As  a  rule  they 
are  intermingled  with  lichen  scrofulosorum  or  with  typical  papulo- 
necrotic tuberculides,  of  which  they  represent  a  superficial  variety. 


568  INFECTIOUS  BACILLARY  DERMATOSES 

The  name  of  ecthyma  terebrans  scrofidosorum  may  be  applied  to 
tuberculides  related  to  the  papulo-necrotic  variety,  but  char- 
acterized by  an  eruption  of  lenticular  or  especially  nummular, 
shallow  and  painless  ulcerations  which  may  coalesce  in  irregular 
patches;  their  course  is  slow,  although  occasionally  acute. 

With  the  exception  of  the  acnitis  type,  which  usually  seems  to 
be  pure,  the  other  varieties  have  a  tendency  to  become  combined 
with  each  other.  They  also  become  associated  with  small  deep 
nodosities,  analogous  to  scrofulous  gummas  of  very  small  size. 

Not  to  mention  the  coexistence  of  a  local,  glandular,  etc.,  tuber- 
culosis, which  is  common,  the  combination  of  papulo-necrotic 
tuberculides  with  aero-asphyxia,  with  pernio,  with  lichen  scrofulo- 
sorum,  with  lupus  erythematodes,  etc.,  is  far  from  unusual. 

As  their  objective  appearance  is  on  the  whole  very  polymorphous, 
when  the  various  cases  are  taken  into  consideration,  the  differential 
diagnosis  may  have  to  be  made  from  acne  vulgaris,  whose  lesions, 
topography  and  course  are  entirely  different;  from  some  forms  of 
folliculitis  decalvans;  and  especially  from  papulo-crusted  or  follicular 
syphilides.  Careful  examination,  however,  will  show  that  one  is 
not  dealing  with  the  folliculoses,  for  the  palmar  and  plantar  regions 
may  be  involved ;  lesions  have  been  met  with  on  the  buccal  mucosa. 
Hidrosadenitis  must  likewise  be  excluded.  In  other  cases  the 
differentiation  is  not  easy  from  frost-bite,  or  lupus  erythematodes 
with  small  patches,  or  still  other  tuberculides. 

The  pathological  anatomy  will  be  discussed  later. 

The  treatment  must  aim  in  the  first  place  at  correcting  the 
general  hygiene  and  nutrition.  So-called  anti-scrofulous  medica- 
tion with  iodides,  cod-liver  oil  and  arsenic,  is  classical  in  these 
cases;  calcium-salts  remedies  are  indicated.  I  have  obtained 
remarkable  results  from  injections  of  calomel  or  soluble  salts  of 
mercury  in  cases  with  a  negative  YVassermann  reaction.  Still 
more  serviceable  are  intravenous  injections  of  arsenobenzol,  com- 
bined with  tuberculin  injections  in  minimal  and  repeated  doses. 
Locally,  applications  of  ichthyol,  methylene-blue,  tincture  of  iodin 
or  iodide  powders,  according  as  the  lesions  are  ulcerated  or  not, 
seem  to  be  useful.  In  obstinate  cases,  recourse  may  be  had  to 
cliinatotherapy,  to  heliotherapy  and  to  cures  at  watering-places 
with  saline,  arsenic  or  sulphur  springs. 

Lupus  Erythematodes. — Although  clinically  and  histologically 
very  different  from  lupus  vulgaris  or  Willan's  lupus,  erythematous 
or  Cazenave's  lupus  is  likewise  destructive  and  disfiguring;  hence 
its  name.  There  is  not  so  much  difference  in  its  true  nature;  if 
lupus  erythematodes  is  an  erythemato-atrophic  tuberculide,  as 
there  is  good  reason  to  believe. 


TUBERCULOSIS  569 

Symptoms. — Lupus  erythematodes  consists  of  distinctly  cir- 
cumscribed red  patches,  covered  with  adherent  scales;  they  are 
only  slightly  infiltrated  and  have  a  tendency  to  become  atrophied 
at  their  center;  their  course  is  slow;  they  occupy  with  predilection 
the  face,  the  ears,  the  scalp,  the  back  of  the  hands  and  the  fingers. 

Each  of  these  features  deserves  separate  study. 

The  redness  is  constant,  sometimes  of  a  light  pink  or  again  of 
a  carmine  or  livid  shade.  It  results  from  a  persistent  erythematous 
inflammation  and  fades  under  vitropressure.  Very  frequently, 
however,  the  congestion  is  accompanied  by  the  existence  of  a  fine, 
reticular  or  stellate  network  of  telangiectatic  capillaries  and  some- 
times by  punctiform  hemorrhages. 

The  scaling  is  very  characteristic  but  varies  greatly  in  degree. 
In  typical  cases,  a  very  adherent,  more  or  less  continuous,  hyper- 
keratosis is  demonstrable,  formed  by  fine,  greasy,  dirty-white  or 
chalky  lamellae  or  stratified  layers,  which  often  look  as  if  imbedded 
in  a  depression  of  the  epidermis;  rarely,  the  desquamation  is  psoriat- 
iform.  When  this  hyperkeratosis  is  slightly  marked,  it  consists 
simply  of  a  whitish  stippling  around  the  follicular  orifices.  The 
thick  lamellar  or  chalky  layers  present  small  horny  processes  on 
their  deep  aspect,  which  penetrate  into  the  follicles  and  correspond- 
ing depressions  of  the  epidermis.  This  punctate  cornification  is 
one  of  the  characteristic  symptoms  of  lupus  erythematodes. 

The  infiltration  is  very  slightly  marked  and  usually  consists  of 
a  slight  turgescence  of  the  borders  of  the  spot,  the  center  being, 
on  the  contrary,  depressed.  Cardboard  induration  or  discoid 
elevation  of  the  patches  is  exceptional. 

On  the  other  hand,  cicatricial  atrophy  is  invariable  and  char- 
acteristic, although  very  variable  in  degree  and  depth.  Unna,  on 
this  account,  gave  lupus  erythematodes  the  name  of  ulerythema 
centrifugum  (dvkr)  =  cicatrix).  The  cicatricial  atrophy  (p.  339) 
results  from  absorption,  without  ulceration,  of  part  of  the  cutis  and 
of  the  infiltration.  When  mild  and  superficial,  it  manifests  itself 
as  a  delicate  white  sclerotic  network,  with  grayish  punctiform 
meshes,  or  as  a  thin  and  flexible,  not  very  noticeable  patch;  it  is 
usually  depressed,  pearly  white  and  slightly  indurated;  the  deep 
forms  of  lupus  erythematodes  leave  a  white  sclerotic  spot,  without 
hairs  and  glands,  sometimes  squamous  or  pigmented. 

The  tenderness  of  lupus  erythematodes  spots  on  contact,  pres- 
sure and  especially  scratching,  is  a  sufficiently  constant  symptom 
to  merit  attention. 

The  outlines  of  the  spots  are  sharp,  rounded,  oval  or  polycyclic; 
they  are  always  bordered  by  a  narrow  erythematous  margin,  even 
when  the  central  redness  is  concealed  by  the  hyperkeratosis. 

According  to  the  relative  importance  of  the  dermic  and  the 


570 


INFECTIOUS   BACILLARY    DERMATOSES 


epidermic  lesions,  i 
appearances  which 
employed 


ade  between  different  clinical 
pecial  names  still  sometimes 
herpes  cretaceus  of  Devergie, 


distinction  is  n 

have  received 
A  case  is  described  as 
when  a  massive  surface  hyperkeratosis  is  present;  as  acneiform 
lupus,  when  the  hyperkeratosis  is  especially  marked  at  the  pilo- 
sebaceous  orifices;  as  seborrhea  congestiva  (Hebra);  or  as  erythemato- 
follicular  lupus  (E.  Besnier),  when  there  are  oily  crusts  provided 
with  very  apparent  conical  processes,  penetrating  into  the  follic- 
ular orifices;   as  erythema  eentrifugum   of    Biett,  when  congestion 

fine    desquamation    predominates.     In    lupus 


associated     with 

exanthematicus  the  lesions  are  still  less  marked. 

It  is  noteworthy  that  in  the  majority  of  the  cases  the  characters 
are  not  pronounced,  or  they  are  mixed  so  that  their  development  is 
relied  upon  fully  as  much  as  their  morphology  for  the  description  of 
the  following  varieties: 


Fig.   173.— F 


A.  Lupus  erythematodes  discoides,  or  the  fixed  form,  begins  as 
one  or  several  congestive,  slightly  infiltrated  spots,  promptly 
covered  with  adherent  scales,  spreading  very  slowly  like  a  grease 
spot;  their  duration  is  counted  by  years.  The  hyperkeratosis  and 
infiltration  are  usually  very  marked.  The  subsequent  cicatrix  is 
very  atrophic;  on  the  nose  and  ears  it  adheres  to  the  cartilages 
which  are  themselves  atrophic,  hence  rigidity,  thinning  and  notable 
deformity  of  these  parts.  Recrudescence  of  the  lesions  in  the 
cicatrix  is  not  uncommon.     This  form  is  extremely  obstinate. 

Discoid  or  fixed  lupus  erythematodes  (Fig.  173)  preferably 
occupies  the  cheeks,  the  ridge  of  the  nose,  the  temples,  the  ears, 
the  forehead,  the  scalp,  the  neck  and  more  rarely  the  back  of  the 
hands.  Not  infrequently  it  is  arranged  as  a  continuous  patch 
symmetrically  covering  the  nose  and  both  cheeks,  known  as  butter- 


TUBERCULOSIS  571 

fly'or  bat-wing  lupus  (vespertiUo).     The  spots,  however,  may  also 
be  irregularly  scattered,  sometimes  there  is  only  a  single  spot. 

Localization  on  the  buccal  mucosa  is  generally  considered  as 
rare,  although  Th.  Smith  (1906)  found  it  in  16  out  of  56  cases. 
Most  commonly  it  occupies  the  posterior  aspect  of  the  lower  lip, 
where  the  extension  of  a  red  festooned  or  frayed  surface  from  a 
lupus  patch  beginning  on  the  free  border  of  the  lip  may  be  observed. 
Cases  of  lupus  erythematodes  of  the  mucous  surface  of  the  cheeks 
or  palate  are  not  very  numerous;  lesions  have  been  observed  even 
on  the  tongue,  in  the  form  of  a  red  or  purplish  spot  with  a  parch- 
ment-like center  and  radiating  leukoplasic  margins,  resembling 
buccal  lichen  planus.  The  diagnosis  can  be  confirmed  only  on  the 
basis  of  a  coincident  lupus  erythematodes  of  the  face,  or  through 
biopsy. 

B.  Lupus  Erythematodes  Migrans  or  Erythema  Centrifugum  of 
Biett. — Cases  taking  a  relatively  rapid  course  are  connected  by 
imperceptible  transitions  with  stationary  lupus  erythematodes  and 
their  association  is  not  uncommon. 

A  tendency  to  symmetry,  to  bat-wing  form,  to  involvement  of 
the  ears  and  the  hands,  is  much  more  marked  in  lupus  migrans. 
The  mucous  membranes  were  never  found  to  be  involved. 

The  initial  rose-colored  spots  grow  in  a  few  weeks,  often  present- 
ing raised  borders  due  to  a  soft  infiltration  and  a  central  depres- 
sion; they  may  become  confluent  in  extensive  surfaces. 

Desquamation  is  moderate  and  may  be  compared  to  that  of 
pityriasis  or  psoriasis  or  seborrhea. 

The  affection  undergoes  exacerbations,  interrupted  by  long 
stationary  stages.  After  healing,  the  cicatrix  may  be  but  slightly 
noticeable.  The  differential  diagnosis  from  rosacea  is  sometimes 
difficult. 

C.  Lupus  Pernio. — There  is  no  agreement  as  to  the  identity  of 
lupus  pernio,  lupus  frost-bites  or  chilblain  lupus  of  Hutchinson 
and  its  relations  with  lupus  vulgaris  on  the  one  hand  and  with 
lupus  erythematodes  on  the  other.  Lupus  pernio  presents  itself 
in  the  form  of  a  bluish-red  edematous  swelling  with  diffuse  borders, 
occupying  the  nose,  the  malar  regions,  the  ears,  the  back  of  the 
hands  and  the  fingers  and  more  rarely  the  toes;  it  develops  under 
the  same  conditions  as  frost-bite  and  is  not  infrequently  com- 
bined with  acro-asphyxia,  with  papulo-necrotic  tuberculides,  with 
angiokeratoma,  etc.  Sometimes  there  is  considerable  analogy 
with  Raynaud's  disease.  The  lesions  may  become  atrophied  or 
ulcerated,  giving  rise  to  disfiguring  scars.  The  affection  lasts 
many  years,  with  prolonged  remissions  which  occur  especially  in 
the  warm  season. 

When   vitropressure   or   histological    examination   after   biopsy 


572  INFECTIOUS  BACILLARY  DERMATOSES 

shows  yellowish  nodules  analogous  to  lupus  nodules  in  the  spots  or 
patches  as  is  seen  particularly  on  the  nose,  the  condition  would 
seem  to  be  a  true  lupus  pernio,  representing  a  pathological  type 
related  to  the  sarcoids,  for  which  the  name  of  "benign  lympho- 
granuloma" has  been  proposed  (J.  Schaumann). 

Swollen  erythematous  patches,  with  an  atrophic  central  depres- 
sion, situated  especially  on  the  hands  and  fingers,  may  be  said  to 
be  characteristic  of  chilblain  lupus,  which  is  probably  related  to 
lupus  erythematodes.  Both  forms  are  entitled  to  classification 
under  the  heading  of  tuberculides. 

D.  Lupus  Erythematodes  K.ranthematicus. — Under  this  name  are 
described  various  rather  rare  erythematous  tuberculides,  character- 
ized by  lilac-red,  finely  scaly  centrifugal  spots  becoming  super- 
ficially confluent.  They  may  spread  in  two  or  three  weeks  from 
the  face  and  hands  to  the  neck,  the  trunk  and  the  limbs. 

The  acute  form,  described  by  Kaposi  in  1S72,  has  been  observed 
either  in  young  women  already  suffering  from  stationary  lupus  ery- 
thematodes of  the  face;  or  primarily.  The  primary  variety  was 
investigated  in  1908  by  G.  Pernet,  who  collected  10  cases,  9  of 
which  occurred  in  women.  The  course  is  rapid,  febrile,  with 
arthralgias,  albuminuria  and  severe  general  disturbances;  it  almost 
invariably  leads  to  death  in  a  few  weeks  or  months,  through  toxemia 
or  through  lesions  of  the  respiratory  apparatus,  the  kidneys  or 
the  meninges. 

In  the  subacute  form,  the  spots  are  disseminated  and  the  general 
phenomena  are  absent,  lengthy  remissions  occur  and  retrogression 
is  possible. 

The  dermatosis  designated  as  erysipelas  perstans  faciei  by  Kaposi, 
or  as  erythema  perstans  by  Jadassohn,  in  which  the  red  and  edema- 
tous patches  appear  in  a  given  region,  preferably  in  the  center  of 
the  face,  possibly  belongs  to  the  same  type. 

Lupus  erythematodes  exanthematicus  usually  has  no  evident 
tendency  toward  atrophy. 

Diagnosis. — Lupus  erythematodes  is  distinguished:  from  rosacea, 
by  the  limitation  of  the  red  spots  and  by  their  scaly  atrophic 
character;  from  psoriasis  and  psoriatiform  eezematides,  by  its 
punctate  adherent  hyperkeratosis  and  by  its  tendency  to  atrophy; 
from  senile  keratosis,  by  the  age  of  the  patients,  by  its  more  pro- 
nounced redness  and  its  non-verrucous  surface. 

The  cicatrices  of  lupus  erythematodes  of  the  scalp  differ  from 
those  of  pseudofavus,  favus  and  scleroderma  in  that  they  have 
followed  upon  a  stage  of  severe  reddening  with  hyperkeratosis. 
On  the  face  or  on  the  body,  they  must  be  distinguished  from  the 
idiopathic  macular  atrophies  (p.  344) ;  this  is  sometimes  extremely 
difficult  (Thibierge). 


TUBERCULOSIS  573 

I  repeat  that  the  differential  diagnosis  from  papulo-necrotic  tuber- 
culides, frost-bite  and  other  tuberculides  may  be  very  puzzling,  but 
is  of  minor  importance. 

Lupus  erythematoides  (p.  554)  is  characterized  by  lupomas  which 
are  sometimes  difficult  to  make  out  without  the  aid  of  biopsy. 

Etiology  and  Character. — Lupus  erythematodes  is  observed  very 
rarely  in  children  before  the  eighteenth  year  or  in  aged  individuals 
after  sixty  years;  it  is  common  from  twenty-five  to  forty-five  years, 
especially  in  the  female  sex  and  in  cold  climates.  [In  American 
dermatological  practice  it  occurs  once  in  about  three  hundred  cases 
of  skin  diseases.]  General  circulatory  disturbances,  acro-asphyxia, 
a  tendency  to  facial  erythrosis  and  consequently  the  gastro-intestinal 
and  utero-ovarian  disturbances  which  are  often  primarily  responsible 
for  these  conditions  are  thought  to  be  predisposing  factors. 

The  most  interesting  question,  however,  concerns  the  relations 
of  lupus  erythematodes  with  tuberculosis.  It  results  from  an 
international  inquiry  conducted  by  the  Annates  de  Dermatologie 
(April,  1907),  that  only  a  little  less  than  one-half  the  authors 
accept  its  tuberculous  origin,  which  has  been  conceded  in  France 
since  1881.  It  has  not  been  demonstrated,  but  the  opposite 
theories,  which  claim  a  toxinic,  nervous  or  microbic  pathogenesis, 
are  still  less  firmly  grounded.  Lupus  erythematodes  is  interpreted 
by  Brocq  as  a  cutaneous  reaction,  which  may  result  from  a  variety 
of  causes,  the  most  common  cause  being  tuberculous  infection.. 
[This  very  nearly  represents  the  opinion  of  Jadassohn  also.]  The 
following  facts  must  be  kept  in  mind:  Many  patients  suffering 
from  lupus  erythematodes  are  tuberculous  or  very  probably  so; 
a  few,  however,  seem  actually  free  from  tuberculosis.  I  have 
repeatedly  seen  patches  of  lupus  erythematodes  developing  in 
connection  with  "scrofulous"  lesions.  The  general  tuberculin 
reaction  is  inconstant  in  these  patients;  the  local  reaction  is  absent 
in  practically  all  of  the  cases.  The  histological  lesions  are  inflam- 
matory and  not  tubercular  [in  the  anatomical  sense] ;  giant  cells  are 
rare,  no  bacilli  are  found;  these  features  are  shared  by  several  types 
of  tuberculides. 

However,  although  it  must  be  admitted  that  the  number  of 
cases  is  very  small,  Gougerot  as  well  as  Br.  Bloch  and  Fuchs  suc- 
ceeded in  rendering  guinea-pigs  tuberculous  through  inoculation 
with  tissue  from  lupus  erythematodes. 

Summarizing,  it  may  be  stated  that  lupus  erythematodes  is 
certainly  not  a  cutaneous  tuberculosis  like  lupus  vulgaris;  never- 
theless, on  account  of  its  pathological  relations,  it  may  be  grouped, 
although  with  some  reservations,  among  the  tuberculides. 

Treatment. — Without  being  positively  grave,  lupus  erythematodes 
is  disfiguring  and  very  obstinate;  it  is  rare  for  patients  suffering 
from  the  disease  to  reach  an  advanced  age. 


574  INFECTIOUS  BACILLARY  DERMATOSES 

The  local  treatment  must  be  governed  by  the  clinical  form. 
One  must  avoid  attacking  with  caustic  agents  superficial  spots 
which  max-  disappear  practically  without  a  trace.  In  a  general 
way,  it  is  advisable  to  begin  always  by  cautiously  testing  the 
patient's  capacity  of  reaction,  by  means  of  astringent  lotions,  like 
lead  water,  or  by  applying  weak  ichthyol  or  resorcin  pastes  alter- 
nating with  bland  powders. 

Gradually  more  energetic  methods  are  employed  and  these  must 
be  varied  in  the  course  of  the  treatment.  Painting  with  iodin, 
carbolic  acid,  arsenic;  pyrogallol,  resorcin,  salicylic  acid,  oil  of  cade 
or  mercurial  plasters,  etc.,  are  usually  valuable. 

One  of  the  best  alterative  agents  is  potash  soap,  which  is  applied 
during  a  time  progressively  lengthened  from  half  an  hour  to  eight 
or  ten  hours,  to  the  point  of  producing  an  inflammatory  reaction, 
which  must  then  be  controlled  and  the  soap-treatment  several  times 
repeated. 

In  the  superficial  and  actively  extensive  forms,  high-frequency 
currents  sometimes  yield  remarkable  and  rapid  results. 

In  the  stationary  form,  crossed  linear  scarifications  or  interstitial 
ignipuncture  with  the  galvanocautery,  more  or  less  deep  according 
to  the  case,  constitute  a  classical  treatment,  the  only  objections 
to  them  being  that  they  are  rather  painful  and  somewhat  slow  in 
action. 

Phototherapy  is  rarely  successful;  radiotherapy  or  radium  are 
preferable,  but  difficult  to  apply,  requiring  extreme  care  in  this 
particular  instance.  [I  have  seen  excellent  results  follow  the  use  of 
the  Kromayer  lamp  applied  with  pressure.] 

On  the  whole,  the  therapy  of  lupus  erythematodes  is  extremely 
disappointing.  Patience  and  diplomacy  are  called  for.  It  is 
important  not  to  neglect  hygienic  measures  and  general  treatment 
which  is  identical  with  that  of  an  attenuated  tuberculous  infection. 
Long-continued  administration  of  arsenic  and  especially  of  quinin 
in  large  doses,  combined  with  iodin  externally  has  been  justly 
recommended. 

Pathological  Anatomy  of  the  Cutaneous  Tuberculoses  and  Tuber- 
culides. This  group  of  diseases  comprises  an  entire  series  of  lesions, 
from  the  most  obvious  bacillary  tubercles  to  atypical  and  relatively 
common  reactions. 

Tuberculosis.  —There  exists  no  tuberculous  affection  where  better 
tubercles  are  found  than  in  tuberculous  ulcer  (Fig.  101).  It  seems 
unnecessary  to  describe  them  here.  They  are  arranged  or  scattered 
ncai'  the  floor  and  the  borders  of  the  loss  of  substance,  but  are  often 
only  slightly  evident  near  the  surface  of  the  nicer  itself.  Koch's 
bacilli  are  abundantly  present.  Furthermore,  there  is  a  demon- 
strable inflammation  of   the  connective  and   muscular  tissues,  as 


TUBERCULOSIS  575 

well  as  vascular  lesions;  their  degree  and  their  extent  are  variable, 
in  different  cases. 

The  yellow  granules  of  Trelat  are  due  sometimes  to  intrapapillary 
or  subpapillary  agminated  tubercles,  undergoing  a  caseous  degener- 
ation; in  other  cases  to  small  superficial  abscesses  due  to  secondary 
infections. 

A  tuberculous  gumma  in  its  formative  stage  consists  of  a  mass 
of  tubercles  with  typical  nodules,  in  course  of  caseation.  Bacilli 
are  rarely  present  in  considerable  number.  Sometimes  the  new- 
formation  is  encysted  in  a  fibrous  sheath,  perhaps  resulting  from  the 
dilatation  of  a  lymph- vessel  cavity;  more  frequently  its  boundaries 
are  diffuse.  In  the  stage  of  evacuation  of  the  gumma,  the  tubercles 
are  hidden  in  an  abundant  inflammatory  tissue  where  they  are  not 
so  readily  demonstrable. 

In  tuberculosis  verrucosa,  lupus  scleroticus  and  anatomical 
tubercle,  there  are  well-marked  hyperkeratosis  and  hypergranulosis, 
hypertrophied  interpapillary  proliferations,  elongated  but  very 
irregular  and  uneven  papillae.  The  appearance  at  first  sight  is  that 
of  an  ordinary  papilloma,  sometimes  of  a  verrucous  nevus.  But  the 
papillary  body  and  the  cutis  are  infiltrated  with  abundant  round 
cells,  sometimes  collected  in  miliary  abscesses.  Moreover,  scanty  but 
very  typical  tubercles  separated  by  sclerotic  tissue  may  be  seen  here 
and  there  in  the  deeper  portions  of  the  cutis.  Bacilli  are  present  in 
variable  number ;  the  result  of  guinea-pig  inoculation  is  always  p  ositi ve . 

In  fungoid  tuberculosis,  the  tubercles  and  the  bacilli  are  very 
thinly  scattered  in  ordinary  infiltration  tissue. 

The  pathological  anatomy  of  lupus  vulgaris  is  somewhat  different 
in  different  cases.  The  most  characteristic  appearance  has  been 
described  elsewhere  in  this  book  (Fig.  89).  The  collections  of 
tubercles  may  be  rich  in  giant  cells  or  without  these  and  composed 
solely  of  epithelioid  cells ;  sometimes  the  latter  are  absent  and  nothing 
is  demonstrable  but  a  diffuse  infiltration  of  lymphoid  and  plasma 
cells,  interspersed  with  enormous  giant  cells;  the  last-named  struc- 
ture belongs  especially  to  ulcerative  and  exuberant  lupus. 

The  lupus  tissue  in  all  cases  is  distinctly  circumscribed;  the  con- 
nective tissue  and  elastic  fibers  stop  at  its  circumference;  this 
fact  explains  the  softness,  the  translucidity  and  the  very  evident 
clinical  boundary  of  lupomata. 

The  lupus  infiltration  is  situated  at  a  very  variable  depth  accord- 
ing to  the  clinical  form;  under  the  epidermis,  in  the  corium,  or  as 
far  as  the  hypoderm.  In  the  last  named  layer  or  perhaps  at  a  certain 
distance  from  the  apparent  nodule,  it  is  not  uncommon  to  meet  with 
tuberculous  infiltrations  following  the  lymphatic  or  venous  routes, 
or  with  aberrant  islands,  accounting  for  the  very  frequent  recrudes- 
cences after  a  destruction  supposed  to  be  complete. 


576  INFECTIOUS  BACILLARY  DERMATOSES 

The  connective  tissue  of  the  vicinity  is  often  edematous  and 
interspersed  with  lymphoid  cells,  sometimes  frankly  suppurating  in 
cases  of  lupus  with  a  rapid  course.  The  question  has  arisen:  is  this 
inflammatory  reaction  due  to  a  special  virulence  of  the  bacillus 
or  to  secondary  infections?  In  other  cases,  there  is  a  fibrous  reaction 
with  a  tendency  to  encapsulation  of  the  newformation,  more  par- 
ticularly in  the  forms  capable  of  undergoing  absorption.  Lupus 
cicatrices  often  enclose  latent  nodules. 

The  epidermis  is  sometimes  passive,  distended  and  atrophic, 
whereas  in  other  cases  it  proliferates,  vegetates  and  may  grow  so 
exuberantly  that  certain  vegetating  or  papillomatous  cases  of  lupus 
or  framboesiform  tuberculosis  are  suggestive  of  lupus-epithelioma. 
In  proliferating  lupus  of  an  ulcerative  appearance,  the  epidermis  is 
often  found  to  be  reduced  to  its  deep  layers. 

Lupus  is  so  poor  in  bacilli  that  their  demonstration  discourages 
the  majority  of  histologists  and  very  few  have  pursued  it  to  the  end. 
From  forty  to  sixty  slides  often  must  be  studied  before  a  bacillus 
is  encountered.  The  human  bacillus  is  responsible  for  most  of  the 
cases. 

Inoculation  into  guinea-pigs,  which  react  readily,  necessitates 
the  injection  of  at  least  50  cgm.  of  lupus  tissue,  to  be  convincing; 
even  under  these  conditions,  it  fails  in  one-third  of  the  cases.  The 
virulence  of  the  bacillus  is  usually  moderate  and  exceptionally 
attenuated.  The  tuberculin  test,  which  is  always  positive  requires 
doses  of  yo"  of  a  milligram  to  1.5  mgr. 

On  the  whole,  lupus  vulgaris  is  certainly  a  cutaneous  tuberculosis, 
although  in  numerous  respects  it  is  related  to  the  tuberculides. 

Tuberculides. — The  histological  lesions  of  the  tuberculides  are 
not  uniform  in  character.  Sometimes  they  have  a  tubercular 
structure,  like  the  most  positive  bacillary  tuberculosis,  representing 
what  I  have  named  the  tubercular  type,  or  Type  A;  in  other  cases, 
they  are  of  ordinary  inflammatory  character,  representing  my 
non-tubercular  type  B  (also  named  atypical  cutaneous  tuberculosis 
by  Pautrier,  non-tubercular  inflammatory  tuberculosis,  by  Gougerot 
and  numerous  authors).  I  was  led  formerly  to  believe  that  the 
different  tuberculides  followed  one  or  the  other  type  of  lesion,  but 
have  since  recognized  that  the  two  aspects  may  coexist  or  succeed 
one  another  in  the  same  clinical  form. 

At  any  rate,  it  is  usual  to  find  typical  tubercles  in  lichen  scrofulo- 
sorum,  where  they  are  situated  at  the  level  of  the  papillary  body; 
they  are  also  met  with  in  the  hypodermic  sarcoids  and  in  erythema 
induratum. 

In  the  cutaneous  sarcoids  of  Boeck,  the  infiltration  as  in  some 
cases  of  lupus  vulgaris  and  especially  in  lupus  pernio,  is  composed 
for  the  most  part  of  circumscribed  collections  of  epithelioid  cells. 


TUBERCULOSIS  577 

In  the  papulonecrotic  tuberculides,  the  initial  lesion  is  a  small 
necrotic  focus  of  the  connective  tissue  which  promptly  becomes  sur- 
rounded by  a  reactive  inflammatory  zone,  whose  lymphoid  and 
embryonic  cells  are  preferably  arranged  around  the  vessels.  These 
more  or  less  deeply  situated  foci,  very  superficial  in  acne  cachecti- 
corum  tend  to  rise  and  come  to  lie  under  the  epidermis  which  is 
raised  by  a  little  serum,  finally  drying  up  in  small  crusts.  In  acnitis 
(Darier)  and  at  the  terminal  stage  of  the  papulonecrotic  tuberculides 
(Brissy),  very  distinct  tubercles  may  be  encountered. 

The  essential  lesions  of  lupus  erythematodes  consist  of  the 
following:  in  the  cutis,  a  diffuse  and  especially  perivascular  cellular 
infiltration,  composed  of  small  connective-tissue  cells  and  lympho- 
cytes; plasmocytes  and  polynuclears  are  rare.  Audry  and  Leredde 
found  giant  cells,  which  are  of  exceptional  occurrence  and  usually 
associated  with  a  disintegrated  hair-follicle.  Some  bloodvessels 
are  obliterated  while  others  are  dilated;  small  hemorrhagic  points, 
lymphatic  dilatations  and  often  edema  in  the  papillary  body  occur. 

The  epidermis  is  in  a  state  of  partial  horny  atrophy,  meaning 
that  its  Malpighian  layer  after  at  first  having  been  thickened,  is 
now  atrophied  and  locally  reduced  to  one  or  two  rows  of  deformed 
cells;  its  stratum  granulosum  is  missing  at  numerous  points,  the 
horny  layer  on  the  contrary  is  thickened,  stratified  and  penetrates 
in  cones  into  the  sebaceous  and  sudoriparous  pores  and  into  the  inter- 
papillary  buds;  the  last  named  fact  accounting  for  the  clinical  sign 
of  "punctate  keratosis." 

The  disappearance  of  the  elastic  and  connective-tissue  fibers 
where  the  infiltration  predominates,  indicates  the  mechanism  to 
which  the  final  atrophy  is  due.  The  hairs  fall  out  soon.  The  origin- 
ally enlarged  glands  finally  disappear. 

Briefly,  the  condition  is  an  endoperivasculitis  with  a  tendency  to 
atrophy  and  to  hyperkeratotic  atrophy  of  the  epidermis. 

Koch's  bacilli  have  been  discovered  in  lichen  scrofulosorum 
(Jacobi  and  Wolff)  and  in  erythema  induratum;  with  the  aid  of 
modern  methods,  with  antiformin  or  by  the  Gram-Much  procedure, 
positive  results  although  open  to  controversy  have,  moreover,  been 
obtained  in  nearly  all  the  tuberculides,  including  lupus  erythema- 
todes. 

In  exceptional  instances,  guinea-pigs  have  been  successfully 
rendered  tuberculous  through  lichen  scrofulosorum  (Jacobi,  Wolff, 
Pellizari,  Haushalter,  Lefebvre),  through  erythema  induratum 
(Thibierge  and  Ravaut,  C.  Fox,  Eyre,  Carle),  and  through  lupus 
erythematodes  (Gougerot,  Br.  Block).  Inoculation  into  monkeys 
is  not  more  apt  to  be  successful. 

The  tuberculin  test  yields  inconstant  and  often  not  very  distinct 
results,  although  Jadassohn  obtained  a  positive  local  and  general 
37 


578  INFECTIOUS  BACILLARY  DERMATOSES 

reaction  in  14  of  16  cases  of  lichen  scrofulosorum ;  it  is  also  often 
obtained  in  erythema  induratnm.  I  was  equally  successful  in  the 
three  cases  of  subcutaneous  sarcoids  which  were  examined  from  this 
point  of  view. 

LEPROSY. 

Leprosy  (lepra  of  the  Arabs,  elephantiasis  of  the  Greeks,  spedal- 
sked  of  the  Norwegians,  la  lepre  of  the  French,  Aussatz  of  the  Ger- 
mans) is  a  chronic  infectious  disease,  which  develops  with  periodic 
exacerbations  and  is  caused  by  a  special  microbe,  the  Hansen 
bacillus.  Numerous  and  varied  cutaneous  manifestations  occupy 
a  prominent  place  in  the  symptomatology  of  the  disease. 

Leprosy  seems  to  have  existed  from  the  earliest  times  among  the 
peoples  whose  history  has  come  down  to  us,  notably  in  India, 
Egypt,  Greece  (alphos),  China,  etc.  But  it  was  confused  with 
numerous  contagious  affections,  so  that  the  zaarath  of  the  Bible 
has  nothing  in  common  with  genuine  leprosy  (W.  Dubreuilh  and 
Bargues).  In  the  middle  ages,  after  the  Crusades,  it  became  widely 
distributed  in  Europe;  numerous  leper  asylums  were  erected  (over 
2000  in  France)  which  in  all  probability  erroneously  harbored 
more  than  one  case  of  tuberculosis  or  syphilis. 

[Originating  in  the  Orient,  leprosy  was  spread  over  Europe  by 
the  Roman  armies  and  colonizers.  There  are  ample  records  of  its 
presence  in  France  and  England  long  before  the  Crusades  but  that 
great  movement  of  men  to  and  fro  across  Europe  served  to  increase 
the  number  of  cases  enormously.  In  the  fourteenth  and  fifteenth 
centuries  the  disease  was  common  throughout  the  British  Isles. 
Thereafter  the  epidemic  gradually  faded  and  the  last  autochthonous 
leper  died  in  the  Hebrides  about  a  hundred  years  ago.  The  disease 
was  carried  to  the  West  Indies,  Mexico,  Central  and  South  America 
by  the  early  Spanish  settlers  and  by  negro  slaves  from  Africa.  It 
reached  the  shores  of  the  United  States  in  the  same  way  and  more 
directly  from  the  West  Indies.  In  the  Philippines  with  their  large 
Spanish  and  Chinese  population  leprosy  has  been  endemic  for 
several  centuries.  In  the  Sandwich  Islands  it  was  introduced  about 
the  middle  of  the  last  century.] 

At  the  present  day  this  disease  is  practically  extinct  in  our 
regions.  Autochthonous  cases  are  rare  in  France,  even  in  Brittany 
and  Provence;  Great  Britain,  Belgium,  Switzerland,  Germany, 
Austria,  as  well  as  the  United  States  of  America,  are  free  from  it  or 
have  only  a  few  trifling  local  endemic  foci.  Lepers  are  more  common 
in  Norway,  Italy,  Spain  and  Algeria.  In  the  Balkan  Peninsula, 
in  Southern  Russia,  in  the  Baltic  Provinces  and  in  Iceland,  leprosy 
is  fairly  common. 

Among  the  most   gravely   infected   countries,   I   shall  mention 


LEPROSY  579 

Hindustan,  Persia,  China,  Indo-China,  Japan,  Polynesia  and  not- 
ably New  Caledonia  and  the  Sandwich  Islands ;  Latin  America 
[including  some  of  the  West  Indies]  may  be  considered  as  an 
important  focus;  certain  parts  of  Africa  are  also  more  or  less 
severely  affected. 

[In  the  United  States  the  largest  focus  at  present  is  in  Louisiana 
where  it  has  existed  since  the  first  settlement.  In  the  middle  of  the 
last  century  a  considerable  number  of  cases  were  imported  into  the 
Northwestern  States  by  Scandinavian  immigrants,  but  there  has 
been  no  increase  in  these  regions;  on  the  Pacific  Coast  a  small 
focus  is  due  to  importation  from  the  Sandwich  Islands  and  the 
Orient.  There  are  a  few  sporadic  cases  in  Texas,  Florida  and 
South  Carolina.  In  the  larger  cities,  cases  are  found  among  the 
emigrants  from  Russia,  Italy,  the  West  Indies,  South  America 
and  China.] 

Owing  to  the  facility  and  increasing  frequency  of  communication, 
there  are  numerous  opportunities  for  the  importation  of  lepers  into 
seaports  and  large  cities  all  over  the  world. 

The  authors  to  whom  we  are  indebted  for  most  of  our  knowledge 
on  the  subject  of  leprosy  are:  Danielssen  and  Boeck,  Sr.  (1846), 
Virchow,  Hansen,  Neisser,  Besnier,  Leloir,  Lima,  Zambaco,  Ehlers, 
Jeanselme,  etc. 

Etiology. — Leprosy  is  a  disease  of  mankind  and  respects  no  race, 
no  age,  no  social  station,  nor  any  climate  or  latitude. 

Leprosy  is  caused  by  the  bacillus  which  was  discovered  by  Hansen 
in  1871  and  was  more  accurately  studied  and  stained  by  Neisser. 
It  resembles  the  Koch  bacillus,  but  is  shorter,  more  rigid,  less 
regular  in  form  and  much  more  abundant  in  the  lesions;  it  is  acid- 
fast  and  stains  by  the  Ziehl  method  as  well  as  by  the  methods  of 
Gram,  Weigert  and  Much. 

It  is  not  certain  that  real  cultures  of  the  Hansen  bacillus  have  so 
far  been  obtained;  of  the  positive  results  reported  by  numerous 
authors  on  more  or  less  complicated  culture-media,  none  have 
proved  universally  convincing. 

Inoculation  of  leprous  tissue  into  all  sorts  of  animals  is  usually  a 
failure;  but  Ch.  Nicolle,  in  1905,  apparently  succeeded  in  infecting 
a  Macacus  sinicus,  in  which  nodules  made  their  appearance  on  the 
sixty-second  day. 

The  disease  known  as  "rat  leprosy,"  discovered  by  Stefansky 
in  Odessa  in  1903,  which  is  distributed  over  the  entire  world,  presents 
in  certain  respects,  notably  in  the  characteristics  of  its  pathogenic 
agent,  analogies  with  human  leprosy,  although  it  also  differs  from 
it  very  essentially.  E.  Marchoux,  who  recently  investigated  its 
modes  of  propagation  in  view  of  possible  deductions  applicable  to 
human  leprosy,  found  that  it  is  transmitted  especially  through 


580  INFECTIOUS  BACILLARY  DERMATOSES 

bites  or  contact  with  an  erosion,  with  flies  as  an  accessory  factor 
and  perhaps  sarcoptes  and  demodex,  but  not  stinging  insects. 

Human  leprosy  has  long  been  considered  as  hereditary,  although 
this  interpretation  still  has  its  advocates,  it  is  not  proved  by  indis- 
putable facts;  on  the  contrary,  the  children  of  lepers  are  known  to 
remain  free  from  the  disease,  provided  they  are  removed  at  birth 
from  the  infectious  focus.    Few  births  occur  among  leprous  families. 

The  contagiousness  of  leprosy,  on  the  contrary,  is  unquestionable, 
but  its  mechanism  is  not  known  and  it  seems  to  be  subject  to  certain 
special  conditions.  Thus  lepers  who  have  been  imported  into 
countries  free  from  the  disease,  for  example  Paris  [or  New  York], 
where  more  than  150  lepers  permanently  reside,  do  not  establish  a 
local  epidemic  focus.  Nevertheless  Frenchmen  often  contract  the 
disease  in  countries  where  leprosy  prevails.  This  fact  seems  to 
support  the  theory  of  an  intermediate  host  or  parasitic  carrier  of 
the  contagium,  such  as  a  mosquito  which  does  not  exist  everywhere. 

Exceptional  but  demonstrative  cases  of  transmission  are,  however, 
known  to  have  occurred  in  our  countries,  like  that  of  Hawtrey 
Benson's  Irishman  who  was  infected  after  his  leprous  brother's 
return  from  India,  whose  bed  he  had  shared;  or  that  of  Veyrieres' 
patient  who  contracted  the  disease  in  Nice  through  her  husband. 

In  this  connection  may  be  mentioned  the  extremely  rapid  propa- 
gation of  leprosy  in  the  Hawaiian  Islands  and  in  New  Caledonia, 
for  instance,  where  a  considerable  portion  of  the  population  was 
infected  in  the  course  of  ten  or  fifteen  years. 

Poverty,  dirt,  promiscuity  and  prolonged  contact  are  emphasized 
as  favoring  factors  of  contagion,  which  is  supposed  to  occur  indi- 
rectly, through  the  intermediation  of  clothing  or  ordinary  objects. 
On  the  other  hand,  the  presence  of  ulcerated  tubercles,  the  dis- 
charge of  secretions  containing  large  numbers  of  bacilli,  as  is  often 
true  for  the  nasal  mucus,  the  saliva  and  the  genital  secretions, 
serve  to  render  the  cases  of  "open  leprosy"  more  dangerous.  How- 
ever, the  portal  of  entry  in  the  contaminated  person  is  unknown; 
the  nasal  fossse  in  particular,  perhaps  the  digestive  tube,  the  skin, 
especially  the  skin  of  the  feet  in  bare-foot  populations,  have  been 
considered  as  possible  atria. 

Direct  inoculation  from  man  to  man,  accidental  or  experimental, 
is  often  ineffectual  and  demands  great  caution  when  made  in 
countries  where  leprosy  prevails.  But  the  experiment  performed  by 
Arning,  in  the  Hawaiian  Islands,  on  the  convict  Keanu,  in  whom 
leprosy  made  its  first  appearance  in  the  vicinity  of  the  inoculated 
point,  leaves  little  room  for  doubt. 

The  incubation  of  leprosy  has  a  duration  certainly  very  variable 
and  often  very  prolonged. 

Its  medium  duration  fluctuates  between  three  and  five  years; 


LEPROSY  581 

sometimes  it  seems  reduced  to  a  few  months;  often  it  is  prolonged 
up  to  ten  years  and  extreme  cases  have  been  quoted  of  fourteen 
years  (Landouzy)  and  of  thirty-two  years  ( ?)  (Hallopeau) .  It  will 
be  readily  understood  that  the  incubation  period  cannot  always  be 
accurately  established. 

Symptomatology. — Period  of  Invasion. — The  first  manifestations 
frequently  consist  of  general  disturbances  of  a  rather  ordinary 
character. 

Depression,  weakness,  anemia  and  somnolence,  are  practically 
constant,  as  well  as  rheumatoid  pains,  arthralgias,  backache  and 
neuralgias;  digestive  disturbances  are  also  noted  (anorexia,  dys- 
pepsia, coated  tongue,  transitory  diarrheas)  headache  and  vertigo. 

Fever  is  inconstant  and  often  inconsiderable;  but  it  may  assume 
the  form  of  intermittent  attacks  with  temperatures  of  104°  and  105°, 
suggestive  of  malaria. 

Absence  of  sweating,  or  on  the  contrary  attacks  of  perspiration, 
severe  itching  or  tingling  sensations  and  a  persistent  feeling  of  cold, 
have  also  been  observed. 

Signs  of  a  certain  value  are  furnished  by  a  dull  coloration  of  the 
skin  of  the  extremities,  sometimes  with  local  asphyxia  or  syncope; 
also  by  obstinate  coryza  or  abnormal  dryness  of  the  nasal  fossae 
with  recurrent  epistaxis  occurring  without  an  obvious  cause.  All 
these  symptoms,  the  nature  of  which  is  often  misunderstood, 
persist  during  months  and  years,  extending  into  the  subsequent 
periods. 

According  to  the  tendency  of  the  lesions  to  manifest  themselves 
especially  on  the  integument  or  on  the  nervous  system,  a  distinction 
is  made  between  tubercular  leprosy  [lepra  tuberosum]  and  nervous 
leprosy  [lepra  nervorum}. 

Macular  Period. — No  matter  what  is  to  be  the  ultimate  form  of 
the  disease,  but  especially  in  the  tubercular  form,  an  established 
leprosy  generally  manifests  itself  by  spots  or  leprides,  varying 
greatly  in  color,  dimensions,  abundance  and  duration,  developing 
in  irregular  crops. 

They  occupy  the  face,  the  extremities,  the  extensor  side  of  the 
limbs,  especially  the  buttocks  and  the  back.  They  may  assume  the 
appearance  of  a  polymorphous,  papular  or  nodular  erythema,  with 
general  symptoms,  taking  a  sluggish  course.  Most  commonly  they 
appear  in  the  form  of  erythemato-pigmentary  spots,  of  variable 
size  (Fig.  174),  sometimes  simply  congestive,  or  purely  achromic 
or  hyperchromic.  Although  not  infrequently  pruritic  or  painful 
at  the  onset,  they  are  nearly  always  characterized  by  their  hypo- 
esthesia  or  their  anesthesia,  which  is  usually  of  the  thermo-analgesic 
type.  They  are  diffuse  or  circumscribed  and  frequently  arranged  in 
circles,  rings  or  serpiginous  lines.    After  the  first  appearance  they 


582 


INFECTIOUS  BACILLARY   DERMA  TOSES 


are  often  ephemeral  and  may  vanish  without  leaving  a  trace;  later 
on  they  become  persistent. 

The  erythematous  spots  may  cover  large  areas,  simulating  ery- 
sipelas or  polymorphous  erythema;  as  a  rule,  they  soon  become 
more  or  less  purplish  or  bronzed  or  copper-colored,  or  less  colored 
than  the  background  in  the  colored  races,  and  are  covered  with  fine 
scales;  transitory  at  first,  they  persist  after  a  recrudescence,  spread- 
ing like  a  drop  of  oil  and  becoming  decolorized  at  the  center.  The 
tubercles  usually  develop  upon  these  spots. 


Fig.   174. 


-Ervthemato-pigmented  leprides,  in  a  boy  aged  cloven  years,  son  of 
a  French  official  in  Cayenne. 


The  pure  pigmentary  or  achromic  spots,  belonging  more  par- 
ticularly to  the  nervous  form,  present  all  the  above-mentioned  shapes 
and  an  entire  color-scale,  from  black  at  one  end  to  pure  white  at 
the  other.  They  are  often  leuko-melanodermic,  the  center  being 
depigmented  and  the  circumference  hyperchromic  (morphea  leprosa). 
They  may  simulate  vitiligo  (vitiligo  gravior),  chloasma,  pigmentary 
syphilides,  pityriasis  versicolor,  etc.,  hut  are  characterized  by  their 
anesthesia.  In  colored  individuals,  leprous  achromia  produces  a 
variety  of  "piebald  negroes." 

The  combination  with  erythematous  spots  is  fairly  common  and 
<jives    rise   to    peculiar   checkered    designs. 


LEPROSY  583 

Following  the  macular  period,  or  in  place  of  it,  pemphigus  leprosus 
may  occur,  being  much  more  commonly  observed  in  the  nervous 
form.  It  consists  of  voluminous  but  not  very  numerous  bulla?, 
preferably  affecting  the  back  of  the  hands  and  feet,  the  elbows  and 
the  knees  and  often  the  surface  of  the  achromic  spots.  Evacuation 
of  their  clear  contents  leaves  a  red  or  inflamed  excoriation  which  on 
healing  leaves  a  nacreous  anesthetic  cicatrix,  with  pigmented  borders, 
possessing  great  diagnostic  value. 

The  crops  of  bullae  recur  in  the  course  of  the  trophoneurotic  stage. 

Tubercular  leprosy  [lepra  tuberosum]  the  tubercular  or  nodular  form 
of  leprosy — or  lepre  systematise  tegumentaire  of  Leloir — is  charac- 
terized by  leprous,  tubercles  or  lepromata. 

A  tubercle  which  remained  solitary  for  several  months,  has  in 
rare  instances  been  the  first  manifestation  of  the  disease,  as  observed 
by  Leloir,  Marcano  and  Wurtz,  and  Gougerot;  by  analogy,  this  has 
been  described  as  leprous  chancre. 

The  tubercles  are  sometimes  derived  from  the  slow  and  partial 
transformation  of  erythemato-pigmented  leprides;  in  other  cases 
they  develop  in  crops  with  abundant  lesions,  sometimes  with  febrile 
or  afebrile  general  disturbances. 

Their  vaguely  symmetrical  localization  is  approximately  that  of 
the  spots,  with  a  predilection  for  the  face  and  ears  and  possible 
extension  to  the  mucous  membranes. 

Hypodermic  lepromata  are  also  observed,  perceptible  to  the 
touch  as  circumscribed  nodosities  or  infiltrated  and  nodular  patches 
(Chapter  XIV). 

The  leprous  tubercles  (Fig.  175)  and  the  cutaneous  leprous  infil- 
trations have  been  described  elsewhere  in  this  book  (p.  258),  and 
I  have  pointed  out  their  possible  termination  in  leprous  morphea 
and  in  leprous  ulcers. 

There  still  remains  to  be  traced  the  picture  of  the  topographical 
distribution  of  lepromata.  Not  infrequently  they  lend  a  character- 
istic appearance  to  the  invaded  regions.  In  the  face,  this  aspect 
is  described  as  fades  leonina  or  leontiasis  leprosa;  the  forehead  is 
puckered,  traversed  by  deep  wrinkles;  the  region  of  the  eyebrows 
is  thickened  and  hairless;  the  nose  is  deformed,  thickened  and 
enlarged;  the  cheeks,  the  lips  and  the  chin  are  lobulated  and  the 
beard  is  reduced  to  a  few  thinly  scattered  hairs.  All  these  surfaces 
are  of  a  red,  brownish  or  grayish  color.  In  very  pronounced  cases, 
the  disfigurement  is  such  that  the  race,  age  and  sex  of  the  patient  are 
no  longer  recognizable. 

The  ears  of  lepers  are  typical,  with  an  enlarged  auricle  studded 
with  tubercles  or  seamed  with  cicatrices,  a  thick,  hanging  and 
flabby  lobule  in  which  numerous  "birdshot"  granules  are  demon- 
strable on  palpation. 


:>vi 


INFECTIOUS   BACILLARY   DERMA  TOSKS 


The  scalp  almost  invariably  escapes  and  the  luxuriant  hair  on  the 
head  of  lepers  contrasts  with  their  hairless  face  and  the  loss  of  the 
body-hairs. 

On  the  extremities,  the  elbows,  the  knees  and  the  prominent 
portions,  including  the  fingers  and  toes,  are  deformed  by  brownish 
or  purplish  tubercles.  The  integumenl  as  a  whole  has  a  dusky, 
tawny,  earthy,  in  places  cyanotic  color,  a  flabby,  withered  consist- 
ence and  a  peculiar  dryness.  The  nails  are  dry,  brittle  and  may  fall 
out.  In  the  lower  limbs,  a  pachydermatous  condition  justifying  the 
name  of  elephantiasis  of  the  Greeks  is  not  uncommon. 


i^b 


Fi<;.   175. — Leprous  tubercles  of  the  lace.      Note  the  alopecia  of  the  eye-brows  and 
interstitial  keratitis,  with  iritis  of  the  left  eye. 

Lymph  glands  are  usually  enlarged  early  and  may  attain  an 
enormous  size,  without,  however,  undergoing  suppuration. 

Localization  on  the  mucous  membranes  and  on  the  special  sense 
organs  is  very  common. 

In  the  nasal  fossae,  the  obstinate  bacilliferous  coryza  and  epistaxis 
of  the  onset  urc  followed  by  lepromata  or  ulcers  of  the  septum, 
leading  to  perforation  as  in  syphilis,  with  breaking  down  of  the  nose. 

The  mouth  may  be  the  seat  of  lepromata  or  cicatrices  affecting 


LEPROSY  585 

the  palate,  the  velum,  the  uvula,  the  pharynx  and  the  back  of  the 
tongue. 

The  larynx  is  often  attacked  at  an  early  date,  hence  hoarseness 
of  the  voice,  aphonia,  dyspnea  after  exertion  and  later  on  attacks  of 
suffocation. 

The  eye  is  affected  with  deplorable  frequency,  especially  in  its 
anterior  hemisphere.  Leprosy  here  very  rapidly  gives  rise  to  tuber- 
cles on  the  conjunctiva,  interstitial  keratitis  with  superficial  pannus, 
episcleritis,  iritis;  the  bacillary  infiltration  of  the  iris  is  sometimes 
manifested  by  nodules,  almost  invariably  by  exudates  which  impair 
vision.  The  ciliary  body  is  more  frequently  invaded  than  the  choroid 
and  the  retina.  Attacks  of  glaucoma,  secondary  cataract  and 
atrophy  of  the  eye-ball,  may  hasten  the  loss  of  the  eye. 

Visceral  leprosy  is  here  only  mentioned  by  name;  it  affects  the 
lungs,  where  the  differential  diagnosis  from  tuberculosis  which  some- 
times complicates  it,  is  not  easy  but  possible  by  bacteriological 
methods;  the  digestive  tract,  the  liver,  the  spleen,  the  circulatory 
apparatus,  etc.,  may  also  be  affected. 

Leprosy  of  the  genital  apparatus  is  common,  especially  in  man. 
Orchitis  leprosa  is  observed  in  at  least  one-third  or  one-fourth  of  the 
cases;  it  may  be  acute  at  the  onset;  as  a  rule  it  is  an  insidious 
bilateral  orchiepididymitis,  of  which  the  patient  is  not  aware;  the 
organ  is  smooth  or  nodular,  but  hard  and  undergoes  atrophy.  The 
lesions  lead  to  early  sterility,  without  loss  of  libido  and  later  to 
impotence.  Not  many  data  are  available  on  leprosy  of  the  female 
genital  apparatus;  its  different  parts,  notably  the  ovaries,  may  be 
damaged  and  undergo  sclerotic  atrophic  changes;  according  to 
Babes,  about  70  per  cent,  of  female  lepers  are  sterile. 

The  course  of  tubercular  leprosy  is  very  variable;  it  is  rarely  acute 
and  fatal  in  a  few  months,  but  usually  chronic,  lasting  ten  or  twenty 
years  and  longer.  The  attacks  are  interrupted  by  prolonged  remis- 
sions, with  retrogression  of  all  symptoms,  simulating  a  cure.  These 
remissions  are  the  rule  in  our  countries.  When  the  course  is  pro- 
gressive, the  ulcerations,  the  suppuration,  the  fever  and  diarrhea 
lead  to  marasmus  and  death,  which  often  occurs  as  the  result  of 
severe  local  disturbance  or  a  superadded  complication. 

Lepra  Nervorum. — The  second  ordinary  type  of  established  leprosy 
is  the  generalized  nervous  form  or  lepra  maculo-anesthetica  or  tropho- 
neurotica. 

It  likewise  begins  almost  invariably  with  macules;  it  is  not  certain 
that  these  may  be  entirely  absent.  Frequently  they  are  large  and 
perfectly  symmetrical;  disturbances  of  pigmentation  are  marked. 
The  macular  stage  is  sometimes  indefinitely  prolonged,  so  that  a 
form  of  so-called  macular  leprosy  [lepra  maculosa]  has  been  described. 

In  other  cases,  the  onset  of  the  disease  is  marked  by  pemphigus 


586  INFECTIOUS  BACILLArV  DERMATOSES 

leprosus  which  occurs  in  attacks  sometimes  leading  to  sloughs  and 
frightful  mutilations;  sonic  authors  have  accordingly  recognized  a 
macular  and  bullous  form  of  the  disease,  known  as  Lazarine  leprosy. 

As  a  rule,  nerve  leprosy  is  characterized  by  tumefaction  of  certain 
nerves,  by  anesthesia  and  by  trophic  disturbances  of  the  skin,  the 
muscles  and  the  bony  framework. 

The  nerves  accessible  to  palpation,  notably  the  ulnar  nerve  above 
the  bend  of  the  elbow,  the  external  popliteal,  or  the  superficial  nerves 
of  the  cervical  plexus  or  the  forearm,  are  cylindrically  thickened  or 
more  often  the  seat  of  spindle-shaped  swellings  or  beaded  nodosities. 

Although  painful  at  first,  they  soon  become  insensitive  and  at  the 
same  time  cutaneous  anesthesia  is  developed. 

Neuritis  manifests  itself  by  neuralgic  pains,  sometimes  intoler- 
able, circumscribed  areas  of  pain,  pruritus  unrelieved  by  scratching, 
sensations  of  numbness,  "dead  fingers,"  local  cyanosis,  sudoral 
disturbances,  etc. 

The  anesthesia,  which  possesses  great  diagnostic  value,  was  care- 
fully studied  by  Jeanselme.  It  particularly  affects  the  extremities 
symmetrically,  first  the  lower  limbs,  progressing  from  the  periphery 
to  the  center.  Band-like  at  the  onset,  occupying  for  instance  on 
the  upper  extremities  the  little  ringer  and  the  ulnar  border  as  far  as 
the  axilla,  at  the  lower  limb  the  big  toe  and  the  internal  border  of 
the  foot  and  leg,  it  subsequently  assumes  a  segmentary  type.  It  is 
variably  distributed;  outside  of  the  territory  where  it  is  established, 
there  exists  a  movable  anesthetic  zone,  imperfectly  bounded  by  a 
transitional  area;  at  its  origin  it  is  superficial,  but  shows  a  tendency 
to  increase  in  depth.  The  anesthesia  is  dissociated;  the  tempera- 
ture sense  is  lost  first,  next,  sensibility  to  pain  disappears  and  much 
later  the  tactile  and  pressure  sensations.  Sensory  perversions  and 
retarded  sensation  are  not  uncommon.  Finally  the  loss  of  sensation 
becomes  total,  at  least  at  the  extremities;  deep  burns  may  occur, 
the  patient  remaining  unconscious  of  them. 

Muscular  atrophy  affects  especially  the  face  and  the  extremities. 
In  the  face,  the  orbicularis  palpebrarum  is  first  attacked,  as  a  rule, 
causing  inability  to  close  the  eyes  and  its  sequel*. 

The  forehead,  the  cheeks,  the  circumference  of  the  mouth  are 
attacked  in  their  turn.  The  emaciation  of  the  face,  the  pale  and  wan 
complexion,  the  fixity  of  the  features  with  lagophthalmos,  lend  the 
face  a  strange  appearance,  known  as  "fades  Antonina." 

On  the  hands,  the  muscular  atrophy  affecting  the  thenar  and 
hypothenar  eminences  as  well  as  the  interossei,  leads  to  deformity  in 
the  Inn  11  of  ulnar  Hair,  or  of  boat-shaped  hollows  on  the  back  of  the 
hand,  or  to  one  of  the  types  of  chronic  rheumatism.  It  later  involves 
the  forearm  and  especially  the  extensors  and  sometimes  the  upper 
arm.    There  is  no  paralysis  but  only  a  diminution  in  strength  pro- 


LEPROSY  587 

portionate  to  the  atrophy.  On  the  feet,  the  plantar  muscles  are  the 
first  to  be  attacked,  but  the  atrophy  of  the  anterior  tibial  and  the 
extensors  of  the  toes  attract  more  attention,  causing  a  varus  equinus 
position  and  a  halting  gait. 

The  bony  and  articular  lesions  which  are  characteristic  of  lepra 
mutilans  are  derived  either  from  penetrating  ulcers,  or  from  malum 
perforans,  which  is  frequent  and  is  distinguished  by  its  depth  and 
total  anesthesia,  or  from  panaritium  terminating  in  necrosis,  as  in 
Morvan's  syndrome;  or  from  dry  gangrenes;  and  often  also  from 
bone  absorption  without  external  lesion.  The  foot  and  the  hand 
may  be  reduced  to  irregular  stumps  which  have  been  compared  to 
elephants'  feet  (elephantiasis  of  the  Greeks)  or  to  the  paws  of  seals. 

Nerve  leprosy  takes  a  slower  course  and  has  an  even  longer 
duration  than  tubercular  leprosy;  it  is  not  uncommon  for  it  to  exceed 
twenty  years.  In  the  advanced  stages,  the  condition  of  the  patients 
is  extremely  distressing;  they  are  emaciated,  mutilated,  blinded, 
paralyzed,  suffer  from  intolerable  neuralgias,  persistent  cold, 
unquenchable  thirst,  often  from  infected  ulcers  and  are  sunk  in 
deep  apathy,  melancholia  and  marasmus.  A  toxemic  psychosis  of 
lepers  has  recently  been  described.  Death  supervenes  through 
cachexia,  purulent  infection,  pneumonia,  diarrhea,  nephritis,  and 
occasionally  through  tuberculosis. 

Mixed  Form.  —  It  must  be  understood  that  the  two  preceding 
pictures  of  tubercular  leprosy  and  nerve  leprosy  are  more  schematic 
and  didactic  than  in  conformity  with  the  ordinary  appearances. 

Almost  invariably,  while  one  of  these  groups  of  symptoms  pre- 
dominates, there  occur  the  most  varied  associations  and  com- 
binations. Mixed  or  complete  leprosy  is  by  far  the  most  common, 
either  from  the  start  or  more  frequently  as  a  result  of  modifications 
in  the  course  of  evolution;  the  tubercular  form  especially  tending 
to  become  gradually  complicated  by  nervous  and  trophic  disturb- 
ances. 

Pathological  Anatomy. — Leprous  tubercles  or  lepromata  are  made  up 
of  a  sharply  limited  and  very  coherent  intradermic  infiltration,  under 
a  normal  although  stretched  epidermis;  it  is  separated  from  the 
basal  layer  by  a  thin  band  of  normal  tissue  with  a  wavy  lower  border 
and  is  prolonged  in  cuff-form  around  the  vessels,  which  are  affected 
with  endoperi vasculitis  and  around  the  nerves,  the  lesions  of  which 
are  inconstant,  as  well  as  around  the  glands. 

The  infiltration  is  made  up  principally  of  the  "lepra  cells"  of 
Virchow,  large  cells  with  a  clear  and  vacuolated  protoplasm,  some- 
times polynuclear;  furthermore,  by  connective-tissue  cells,  a  few 
lymphocytes,  mast-cells  and  occasional  plasmocytes;  sometimes 
giant  cells  are  found.  Bacilli  are  more  abundant  than  in  any  other 
microbic  disease;  they  are  arranged  in  clusters  or  bundles,  especially 


588  INFECTIOUS  BACILLARY  DERMATOSES 

in  the  lepra-  and  connective-tissue  cells  and  are  sometimes  extra- 
cellular and  agglomerated  in  a  glairy  substance  (glcea);  the  name 
of  globi  is  applied  to  balls  or  strands  composed  entirely  of  bacilli. 
Caseation  is  not  found  in  lepromas. 

In  recent  spots  or  leprides,  only  perivascular  cuffs  of  round  cells 
are  found,  which  in  the  course  of  the  successive  exacerbations 
become  mixed  with  lepra-cells  at  first  not  very  large.  The  pro- 
gressive increase  and  confluence  of  the  perivascular  infiltrations 
lead  to  the  transformation  of  the  spots  into  tubercles.  In  opposition 
to  prevailing  opinions,  I  showed  in  1897  that  there  are  merely  differ- 
ences in  degree  between  these  two  lesions  and  that  leprides  regularly 
contain,  from  their  onset,  a  number  of  bacilli  which  although  not 
very  considerable  can  nevertheless  be  demonstrated  by  a  suitable 
technic.  [In  1899,  in  Unna's  clinic,  I  was  able  to  demonstrate  a  few 
bacilli  in  the  apparently  normal  skin  of  a  leper  after  a  febrile  attack.] 

The  cutaneous  manifestations  of  leprosy  result  from  bacillary 
embolisms.  Several  authors  have  noted  a  bacillemia  at  the  time 
of  the  exacerbations,  accompanied  by  polynucleosis;  after  the 
crisis  a  transitory  lymphocytosis  follows  and  then  a  persistent 
eosinophilia,  which  is  sometimes  very  marked  (over  30  per  cent, 
according  to  Gaucher  and  Renaut). 

Leprous  neuritis  was  described  by  Virchow.  When  the  nerves 
are  involved,  they  present  the  changes  of  parenchymatous  and 
sclerotic  neuritis,  of  peripheral  origin  and  centripetal  course, 
according  to  Gerlach,  Dehio,  etc.,  or  with  multiple  points  of  attack. 
Abundant  collections  of  bacilli  may  be  found,  especially  in  the 
mixed  form. 

Diagnosis. — The  disturbances  of  the  period  of  invasion  are  gener- 
ally not  referred  to  their  true  cause  until  after  the  appearance  of 
more  significant  manifestations. 

The  question  of  a  possible  leprosy  most  frequently  arises  in  con- 
nection with  erythematous  or  pigmented  spots  or  even  of  tubercles, 
which  may  be  solitary  or  agminated  in  lupoid  or  syphiloid  patches; 
in  other  cases,  attention  is  aroused  by  nervous  disturbances  sug- 
gestive of  polyneuritis,  tabes,  rheumatism,  or  especially  syringo- 
myelia, progressive  muscular  atrophy,  scleroderma,  Raynaud's 
disease,  etc.  The  features  of  these  disturbances,  for  instance 
anesthesia  or  thermo-analgesia  of  the  spots  or  tubercles,  may 
sometimes  suggest  the  diagnosis  of  leprosy  from  the  start.  This 
supposition  will  be  strengthened  by  knowledge  of  the  patient's 
nativity  or  his  sojourn  in  contaminated  countries.  The  important 
point  is  to  keep  leprosy  in  mind. 

The  impression  received  should  always  be  controlled  by  thorough 
inquiry  and  by  laboratory  tests. 

In  the  first  place,  the  so-called  permanent  stigmata  of  leprosy 
must  be  looked  for;  a  dusky,  cyanotic  and  pigmented  coloration 


LEPROSY  589 

of  the  face  and  the  extremities,  with  softness  and  dryness  of  the 
skin;  alopecia  of  the  beard  and  body,  especially  alopecia  of  the 
external  half  of  the  eyebrows;  tubercles  of  the  ear-lobule;  tume- 
faction of  the  nerves,  notably  the  ulnar  nerve;  atrophy  of  the 
muscles  of  the  hand;  anesthesias;  scars  from  bullae  on  the  elbows 
and  knees;  leprous  orchitis;  ocular  manifestations  such  as  paresis 
of  the  orbicularis,  conjunctivitis  and  episcleritis;  rhinitis  with 
hypersecretion  and  epistaxis,  or  even  perforation  of  the  septum; 
hoarseness  of  the  voice,  etc. 

Absolute  scientific  proof  is  furnished  by  the  demonstration  of  the 
bacilli.  These  may  be  found:  by  biopsy  of  a  leproma  or  a  lepride, 
in  sections  or  on  a  smear  preparation  of  a  piece  of  excised  tissue; 
in  default  of  these  procedures,  in  an  extirpated  gland,  with  or  with- 
out the  aid  of  the  antiformin  method;  in  the  nasal  mucus,  especi- 
ally in  the  tubercular  forms  after  the  administration  of  4  grams  of 
iodide  two  days  in  succession  if  necessary. 

The  intradermo-reaction  to  leproline,  which  was  tried  by  Mantoux 
and  Pautrier;  also,  the  sero-agglutination  proposed  by  Gaucher  and 
Abrami;  as  well  as  the  complement-fixation  reaction,  with  a  leproma 
extract  as  the  antigen;  all  these  are  undoubtedly  valuable  methods, 
but  cannot  as  yet  be  described  as  entirely  satisfactory.  It  must  be 
remembered  that  the  blood  serum  of  lepers,  even  those  free  from 
syphilis,  usually  yields  a  positive  Wassermann  reaction  and  that 
eosinophilia  is  common  in  their  blood. 

Prognosis  and  Treatment. — As  to  the  curability  of  leprosy,  it  must 
be  remembered  that  prolonged  remissions  and  arrest  of  the  disease 
which  might  be  considered  as  cures,  have  been  observed  even  in 
countries  where  leprosy  is  endemic. 

Moreover,  there  are  incomplete  (fruste),  benign  forms  in  which 
the  symptoms  are  reduced  to  a  few  spots,  circumscribed  anesthesias, 
partial  amyotrophies,  without  any  further  evolution.  A  recru- 
descence, however,  is  always  possible.  I  have  repeatedly  observed 
the  redevelopment  of  a  checked  leprosy  at  the  time  of  the  patient's 
return  to  the  land  of  origin  of  the  disease.  In  short,  the  possibility 
of  a  cure  of  leprosy  must  be  conceded,  but  with  reservations. 

The  prophylaxis  is  more  important  than  therapeutic  measures. 
The  rule  of  compulsory  reporting  of  cases  and  relative  isolation  of 
the  patients,  although  harsh  in  its  application,  has  yielded  such 
brilliant  results  in  Norway  (243  cases  in  1902,  where  there  were 
2598  in  1856)  that  it  should  be  enforced  in  all  contaminated  coun- 
tries with  modifications  to  suit  conditions.  Occupations  which 
involve  the  risk  of  the  spreading  of  the  contagion  must  be  forbidden 
to  lepers. 

Persons  who  come  in  contact  with  lepers  must  practise  measures 
of  scrupulous  cleanliness  and  strict  personal  hygiene.  The  lepers 
must  be  regularly  bathed,  cleaned  and  bandaged.    As  far  as  possible, 


590  INFECTIOUS  BACILLARY  DERMATOSES 

they  must  be  advised  to  leave  the  infected  countries  and  to  reside 
in  a  healthful  temperate  climate;  under  these  conditions,  lasting 
improvements  and  quasi-cures  are  sometimes  observed. 

No  medication  possesses  an  absolutely  specific  value.  Mercury 
in  soluble  injections,  or  in  the  form  of  calomel  or  gray  oil,  seemed 
to  give  good  results  in  my  experience  and  in  that  of  ('rocker,  Ehlers 
and  Ilaslund.  Iehthyol,  salol  and  salicylates  have  been  recom- 
mended. Treatment  with  arsenobenzol  is  useless.  The  classical 
treatment,  the  best  on  the  whole,  although  its  value  is  disputed, 
is  chaulmoogra  oil,  given  in  doses  of  V  drops,  progressively  increasing 
to  CL  and  CC,  in  emulsion  or  better  in  capsules,  for  periods  of  two 
months,  several  times  during  the  year.  Given  by  the  mouth,  it  is 
often  not  well  tolerated;  I  have  always  been  pleased  with  intra- 
muscular oily  injections  according  to  the  formula  of  Brocq  (chaul- 
moogra oil,  70  cm.,  eucalyptol  30  cm.,  in  sterilized  ampoules  of  5 
cm.).  Its  substitutes,  gynocardic  acid  and  gurjun  balsam,  seem  to 
be  less  active.  Opinions  differ  concerning  the  value  of  nastine 
injections;  the  name  nastine  is  applied  to  products  derived  from 
cultures  of  a  streptothrix  extracted  from  lepromata  by  Deycke; 
these  injections  have  sometimes  proved  injurious. 

[There  is  no  doubt  that  cases  of  leprosy  have  been  arrested  and 
possibly  cured  by  chaulmoogra  oil.  The  problem  is  to  introduce 
the  remedy  in  sufficient  dosage.  Hollmann  and  Dean  (Honolulu) 
have  recently  published  some  very  striking  results  obtained  by 
subcutaneous  injections  of  ethyl  esters  of  chaulmoogra  fatty  acids.] 

Very  hot  baths  bring  great  relief  and  a  sense  of  well-being  to 
lepers,  especially  in  painful  cases. 

The  tubercles  break  down  and  disappear  on  cauterization  with 
the  galvanocautery.  The  ulcers  must  be  kept  very  clean  and  covered 
with  moist  aseptic  dressings;  I  have  obtained  good  results  from 
daily  painting  with  Mencieres  fluid  [therapeutic  notes,  section  3]. 
The  ocular  lesions  are  benefited  by  subconjunctival  mercurial  injec- 
tions, atropin  and  warm  local  douches. 

In  a  general  way,  different  local  measures  are  required,  according 
to  the  nature  of  the  lesions  and  their  seat.  There  is  no  doubt  but 
that  an  actively  and  persistently  treated  case  of  leprosy  takes  an 
infinitely  more  favorable  course  than  when  the  disease  is  left  to  itself. 

The  future  undoubtedly  belongs  to  a  serum  [or  chemotherapeutic] 
treatment  which  still  remains  to  be  discovered. 

GLANDERS. 

Glanders  (French,  la  morve,  German,  Rotz)  [Malleus]  is  a  very 
grave  contagious  and  inoculable  microbic  disease  which  affects 
Soliped  animals  and  is  transmissible  to  man.     It  takes  an  acute  or  a 


GLANDERS  591 

chronic  course.  In  different  cases,  the  general  symptoms,  or  the 
visceral  lesions  or  the  cutaneous  and  mucous  lesions  predominate. 

There  is  no  valid  reason  for  maintaining  the  formerly  made  dis- 
tinction between  glanders  on  the  one  hand,  an  internal  disease 
affecting  the  respiratory  apparatus  and  especially  its  first  passages, 
the  nasal  fossae — and  farcy  on  the  other,  an  external  disease  affecting 
the  skin  and  hypoderm;  for  their  cause  is  identical. 

The  frequency  of  glanders  in  horses  and  asses  had  considerably 
diminished  in  France  before  the  war,  especially  since  the  discovery 
of  malleine,  a  secretory  product  of  the  bacillus,  made  its  early 
diagnosis  possible. 

Human  glanders,  which  is  rare,  is  in  the  vast  majority  of  the  cases 
of  direct  equine  origin,  so  that  those  whose  occupation  puts  them 
in  contact  with  horses  are  apt  to  contract  it  by  cutaneous  inocu- 
lation, without  there  necessarily  existing  a  demonstrable  erosion. 
It  seems  probable  that  infection  may  also  occur  through  the  nasal 


The  bacillus  of  glanders  is  slender  and  shows  clear  spaces  [vacuoles?] 
it  does  not  take  the  Gram-stain;  it  can  be  stained  by  Weigert's 
method  or  by  Nicolle's  method  with  tannin,  but  easily  becomes 
decolorized.  Its  cultures  on  potato  assume  a  tawny,  then  brownish 
color  and  are  characteristic.  It  is  very  dangerous  to  handle  and  can 
be  successfully  inoculated  into  all  laboratory  animals. 

Glanders  pus  introduced  under  the  guinea-pig's  skin  gives  rise 
in  a  few  days  to  a  swelling  from  which  culture-material  may  be 
extracted;  on  injection  into  the  peritoneum  of  a  male  guinea-pig,  it 
gives  rise  in  three  days  to  a  severe  orchitis.  Straus  pointed  out  the 
value  of  the  last-mentioned  reaction  for  the  diagnosis,  but  it  is 
not  absolutely  conclusive.  The  serum  of  animals  having  glanders 
agglutinates  the  glanders  bacillus  at  1  to  500  or  1  to  1000;  but 
agglutinins  may  also  exist  in  some  normal  sera.  The  comple- 
ment-fixation test  is  made  by  means  of  an  extract  of  bacilli  as 
antigen. 

The  anatomical  lesions  of  glanders  are  characteristic  only  when 
they  are  found  to  consist  of  glanders  granulations;  the  latter  have 
been  compared  to  tubercles,  but  are  rather  minute  abscesses,  com- 
posed principally  of  polynuclears;  they  become  necrotic  and  liquefied 
in  their  center;  a  peculiar  fragmentation  of  the  nuclei  occurs, 
known  as  chromatorhexis. 

The  clinical  forms  are  multiple  and  very  dissimilar : 

Acute  glanders  is  a  blood-infection,  a  septico-pyemia,  which 
occurs  primarily  or  as  the  result  of  cutaneous  inoculations  (farcy 
chancre)  and  sometimes  as  the  termination  of  the  chronic  form. 
It  assumes  a  typhoid  or  rheumatoid  course,  or  especially  that  of 
pyemia,  with  a  remittent,  later  an  irregular  fever,  great  weakness, 


592  INFECTIOUS  BACILLARY  DERMATOSES 

arthritis,  respiratory  symptoms,  a  grave  general  condition;  it  kills 
in  five  to  twenty  days. 

Its  cutaneous  manifestations  may  consist  at  the  onset  in  an 
ascending  lymphangitis  of  the  limbs  promptly  followed  by  abscesses; 
or  in  erysipeloid  swelling  of  the  face,  of  dark  red  color,  with  diffuse 
borders,  without  elevation,  on  which  blisters  or  sloughs  make  their 
appearance;  ultimately,  after  several  days,  a  disseminated  pustular 
eruption  develops,  resembling  variola  but  not  umbilicated  and  with 
a  tendency  to  ulceration  and  gangrene;  sometimes,  abscesses  appear 
and  as  they  multiply  cover  the  limbs  with  so-called  "farcy-buds," 
(acute  farcy). 

Chronic  glanders  behaves  like  a  localized  infection  with  a  tendency 
to  become  generalized  in  exacerbations.  It  manifests  itself  as 
phagedenic  penetrating  ulcers  and  abscesses;  these  are  situated  on 
the  face  or  on  the  limbs.  The  clinical  picture  becomes  complicated 
by  general,  febrile,  articular,  testicular,  digestive  and  respiratory 
disturbances  and  usually  terminates  in  acute  glanders;  a  cure  is  rare; 
as  a  rule  it  is  merely  apparent  or  temporary.  The  duration  is  from 
eight  to  fifteen  months  or  sometimes  several  years. 

Mutilating  glanders  of  the  face  is  the  most  interesting  form  for  the 
dermatologist.  It  begins  with  tuberculo-ulcerative  lesions  of  the 
nasal  fossae  or  the  buccal  mucosa;  by  extension  and  by  accessory 
dermic  abscesses  originating  in  the  vicinity,  the  ulceration  (which 
has  a  puckered  floor,  livid  margins  and  a  profuse  discharge  of  yel- 
lowish pus)  reaches  the  face,  destroys  the  soft  portions  of  the  nose, 
the  cheeks,  the  lips  and  sometimes  the  nasal  septum,  exposing  the 
bones  without  attacking  them;  the  glands  are  usually  enlarged. 
Festooned  borders,  as  if  gnawed  by  the  teeth  of  mice,  and  pustules 
or  aberrant  sloughing  ulcers  are  features  which  should  attract 
attention.  Observations  concerning  this  form  of  glanders  are  rare 
(Hallopeau  and  Jeanselme,  Besnier,  E.  Hoffmann);  probably  some 
cases  are  not  recognized.  The  differential  diagnosis  is  difficult  from 
tertiary  or  hereditary  ulcerative  syphilide;  lupus  vorax;  mycoses; 
[espundia]  and  other  phagedenic  affections.  Laboratory  tests  are 
required  for  its  confirmation. 

Treatment. — There  is  no  specific  treatment  for  glanders  at  the 
present  time.  Treatment  with  mercury,  iodides  and  arsenobenzol, 
which  have  been  empirically  tried,  is  without  reliable  effect.  Hence, 
in  cases  with  a  known  initial  lesion  or  in  chronic  ulcers  due  to  glan- 
ders, the  question  of  excision  arises  when  this  is  practicable,  or  of 
cauterization  with  the  actual  cautery.  Radiotherapy  might  serve 
to  dry  out  the  ulcers  and  inhibit  their  progress.  The  abscesses  must 
be  immediately  incised,  scraped  and  disinfected.  But  the  prognosis 
is  extremely  gloomy. 


ANTHRAX— MALIGNANT  PUSTULE  593 

VERRUGA  PERUANA. 

Verruga — also  named  Carrion's  disease  or  Oroya  fever — is  a 
severe  infectious,  frequently  fatal,  disease,  which  is  endemic  in 
some  Peruvian  valleys. 

It  begins  with  septicemic  symptoms,  an  irregular  fever  with 
rheumatoid  pains;  followed  at  the  end  of  a  few  weeks  or  months  by 
an  eruption  of  numerous  scarlet  red  pruritic  miliary  elevations,  which 
increase  in  size  and  become  pedunculated.  There  are  also  larger 
warty  or  fungoid  nodosities  which  appear  in  variable  number. 
Whether  small  or  large,  the  lesions  are  extremely  vascular  and  bleed 
readily;  they  have  at  first  the  structure  of  a  granuloma,  which 
becomes  areolar  through  marked  dilatation  of  the  blood  and  lymph 
vessels.  The  eruption  predominates  on  the  face,  the  neck  and  the 
extensor  surface  of  the  limbs ;  the  mucous  and  serous  membranes  as 
well  as  the  viscera  may  be  invaded. 

The  pathogenic  agent  reported  by  Izquierdo  (1885)  was  redis- 
covered by  Letulle  and  by  M.  Nicolle;  it  is  an  acid-fast  bacillus. 
Others  have  looked  for  it  in  vain  and  suspect  a  special  paratyphoid 
bacillus  or  a  protozoon.  Many  quadrupeds  are  susceptible  to  the 
disease.  Infection  is  supposed  to  occur  through  water  or  through 
stinging  insects.    Verruga  confers  immunity. 

No  specific  treatment  for  the  disease  is  known. 

ANTHRAX— MALIGNANT  PUSTULE. 

Malignant  pustule  is  the  manifestation  of  a  local  inoculation  with 
the  bacillus  anthracis  discovered  by  Davaine. 

In  man,  this  inoculation  almost  invariably  results  from  occupa- 
tional handling  of  diseased  animals,  sheep,  goats,  horses,  cattle,  etc., 
or  especially  of  their  hides,  where  the  very  resistant  anthrax  spores 
persist  indefinitely.  Malignant  pustule  therefore  usually  occupies  the 
exposed  parts  and  is  observed  in  shepherds,  veterinaries,  butchers, 
tanners,  leather-dressers,  brush-makers,  wool-sorters,  workers  in 
horn,  etc.  [Several  cases  of  infection  from  shaving-brushes  have 
been  reported.]  Infection  through  contaminated  flies,  often  held 
responsible  by  the  laity,  is  possible  but  exceptional. 

Comparable  at  the  onset  to  a  flea-bite,  on  which  a  vesicle  promptly 
arises,  the  pustule  becomes  indurated  and  presents  a  brownish  or 
purplish,  granular  lenticular  spot,  which  spreads  and  becomes  a 
slough  encircled  by  vesicles.  Itching  is  rather  severe.  The  circum- 
ference of  the  lesion  is  the  seat  of  a  dark  red  inflammatory  edema, 
sometimes  with  strands  of  lymphangitis.  The  entire  region  is 
invaded  by  a  gelatinous  infiltration.  Finally,  the  slough  is  shed, 
the  gangrene  increases  in  depth  and  in  extent,  the  phenomena  of 
general  infection  appear;  they  consist  of  a  high  fever,  with  a  weak 
38 


594  INFECTIOUS  BACILLARY  DERMATOSES 

irregular  pulse,  difficult  respiration,  sweats,  hemorrhages  and 
delirium;  death  occurs  in  collapse. 

The  duration  of  this  course  varies  from  twenty-four  hours  in 
fulminating  cases  to  twelve  or  fifteen  days.  A  spontaneous  cure  is 
possible,  hut  must  not  be  expected. 

The  name  of  malignant  edema  has  been  employed  for  a  variety  in 
which  the  central  slough  is  absent;  the  symptoms  consist  of  a  soft 
swelling  with  vesicles  and  of  early  signs  of  severe  septicemia. 
Anthrax  edema  is  seen  especially  on  the  eyelids  or  on  the  lips. 

Treatment. — The  old  treatment,  by  excision  or  cauterization  with 
the  actual  cautery,  is  at  all  promising  only  on  a  very  recent  and  still 
doubtful  lesion.  Repeated  injections,  around  the  pustule,  of  a 
carbolized  or  iodine-iodide  solution  have  been  recommended; 
arsenobenzol  has  been  successfully  employed.  These  measures, 
however,  must  make  way  for  serotherapy.  Anti-anthracic  serum, 
introduced  by  Marchoux  in  1895,  since  investigated  by  Sclavo  and 
others,  must  be  employed  in  subcutaneous  injections  of  about  40  c.c. 
and  repeated  several  days  until  the  edema  diminishes;  it  will  cure 
malignant  pustule  provided  it  is  employed  at  the  onset  and  even 
sometimes  when  the  blood-culture  is  already  positive. 

CUTANEOUS  DIPHTHERIA. 

Although  reported  by  Chomel  and  Samuel  Bard  in  the  eighteenth 
century  and  described  by  Trousseau,  cutaneous  diphtheria  has 
become  definitely  characterized  only  since  the  discovery  of  the 
Klebs-Loeffler  bacillus.  It  is  discussed  in  numerous  publications, 
of  unequal  value,  the  most  important  being  the  contributions  of 
Neisser,  Schucht,  as  well  as  the  reviews- of  Marchalko,  Knowles  and 
Frescoln  (1914).  It  must  be  distinguished  from  the  ordinary  erup- 
tions of  urticaria,  erythema  and  purpura,  which  are  frequently 
observed  in  diphtheritic  patients,  especially  in  those  who  have 
received  serum  injections. 

Cutaneous  diphtheria,  due  to  the  growth  of  the  diphtheria 
bacillus  on  the  skin,  is  as  a  rule  secondary  to  involvement  of  the 
mucous  membranes  and  the  result  of  auto-inoculation.  More 
interesting,  but  less  common  are  the  cases  in  which  it  is  primary  and 
exclusively  localized  on  the  external  integument;  these  are  derived 
from  direct  contagion  by  a  diphtheritic  patient  or  a  germ-carrier,  or 
from  indirect  contagion  by  clothing,  bedding,  dressings,  etc.  It 
must  be  kept  in  mind  that  although  diphtheria  principally  attacks 
youthful  individuals,  no  period  of  life  escapes  the  disease. 

Symptoms. — I  ndoubtedly  the  most  common  clinical  form  is  that 
beginning  with  spots  or  patches  of  eczematiform  dermatitis,  situ- 
ated at  the  circumference  of  the  orifices  of  the  mucous  cavities  in 
which  the  diphtheria  runs  its  course,  for  example  under  the  nostrils, 


CUTANEOUS  DIPHTHERIA  595 

around  the  mouth,  the  eyes  or  ears,  and  also  around  the  vulva,  the 
prepuce  and  the  anus,  Wounds  or  even  the  slightest  excoriations, 
located  anywhere,  impetigo,  herpes,  cracks,  intertrigo  and  more 
particularly  surfaces  which  have  been  denuded  by  blisters  (the 
danger  of  which  in  diphtheria  was  emphasized  by  Trousseau),  are 
also  very  apt  to  become  the  seat  of  diphtheritic  infection. 

The  infection  manifests  itself  by  a  serous,  turbid  or  purulent, 
sometimes  fetid  exudation  with  swelling  of  the  affected  surface,  a 
purplish  reddening  and  local  pain;  this  surface  becomes  ulcerated  in 
places;  the  appearance  of  a  buff -colored  false  membrane  is  common, 
but  it  may  be  absent.  Extension  is  rapid  at  times  and  sometimes 
occurs  in  form  of  a  pseudo-membranous  epidermic  elevation,  with 
centrifugal  extension  and  polycyclic  contours ;  or  it  may  result  from 
the  coalescence  of  aberrant  vesicular  lesions,  at  other  times  the  patch 
remains  stationary.  Fever  is  not  constant;  glandular  enlargement 
is  usually  present;  lymphangitis  in  the  vicinity  or  erysipelas  are  not 
uncommon. 

In  the  primary  cases,  the  objective  features  assumed  by  cutaneous 
diphtheria  are  very  variable.  The  most  ordinary  form  is  that  of 
impetigo,  ecthyma  or  impetiginous  eczema  analogous  with  that 
described  above.  In  other  cases,  vesicles  have  been  noted  resem- 
bling those  of  varicella  or  the  vesicle  of  dermatitis  herpetiformis 
(Dawson),  or  bullae  like  those  of  epidemic  pemphigus  of  the  new- 
born or  ulcers  with  distinctly  circulate  margins,  abscesses  and 
gangrenous  patches;  exceptionally  the  lesions  may  be  of  different 
types  in  the  same  patient. 

In  connection  with  this  polymorphism,  it  is  noteworthy  that 
cutaneous  diphtheria  is  often  not  pure,  either  because  it  becomes 
grafted  on  a  preliminary  skin  affection  which  has  served  as  the 
infection-atrium,  or  because  the  diphtheria  bacillus  becomes  asso- 
ciated with  other  microbes,  notably  streptococci  and  staphylococci 
as  is  commonly  the  case.  Hence,  even  since  the  introduction  of 
serotherapy,  cases  of  cutaneous  diphtheria  with  a  fatal  outcome 
are  not  very  rare. 

Diagnosis. — Epidemiological  factors,  or  the  coexistence  in  the 
patient  of  a  lesion  of  the  neighboring  mucous  membranes,  con- 
junctivitis, otorrhea,  rhinitis,  erosions  of  the  buccal  commissures, 
angina  even  if  indefinite,  vulvitis  and  balanitis,  must  arouse  atten- 
tion. The  demonstration  of  a  false  membrane  on  a  dermic  lesion 
is  far  from  being  conclusive.  The  key  to  the  diagnosis  is  really 
furnished  by  the  demonstration  of  the  specific  bacillus  in  smear- 
preparations,  in  cultures  and  by  inoculation  into  guinea-pigs. 

The  Loeffler  bacillus  is  generally  long,  straight  or  slightly  curved, 
in  intermingled  rods;  it  is  Gram-positive;  at  its  swollen  extremities 
it  presents  metachromatic  polar  corpuscles,  staining  by  the  Neisser 
method;  cultures  on  beef  serum,  at  98°,  yield  papular  colonies  of  a 


596  INFECTIOUS  BACILLARY  DERMATOSES 

grayish  white  color  in  eighteen  to  twenty-four  hours;  it  acidifies 
glucose  culture-media;  inoculated  into  guinea-pigs,  it  causes  death 
in  twenty-four  to  seventy-two  hours. 

The  pseudo-diphtheritic  bacillus  of  Hofmann,  from  which  it  must 
be  distinguished,  is  shorter,  ovoid,  has  no  distinct  polar  bodies,  does 
not  acidify  glucose  media  and,  most  important,  does  not  kill  guinea- 
pigs.    The  fusiform  bacillus  of  Vincent  is  Gram-negative. 

Treatment. — Even  in  merely  suspicious  cases,  pending  the  diag- 
nosis, prophylactic  measures  for  the  avoidance  of  contagion  are  in 
order.  The  injections  of  antidiphtheritic  serum  have  entirely 
changed  the  prognosis  of  diphtheria;  large  doses  should  accordingly 
be  employed.  As  an  accessory  measure,  the  lesions  must  be  carefully 
cleansed  and  local  applications  be  made  in  conformity  with  the 
dermatological  type  and  with  the  supposed  microbic  associations. 
The  physician  will  accordingly  prescribe  for  example,  in  a  given 
case  local  applications  of  hydrogen  peroxide  water,  or  strong  dis- 
infectants; moist  antiseptic  or  rather  cytophylactic  dressings,  or 
dressings  with  polyvalent  serum,  etc. 

SOFT  CHANCRE. 

Soft  chancre,  simple  chancre,  or  chancroid  [ulcus  molle]  is  a  specific 
and  contagious  ulceration  due  to  inoculation  of  the  bacillus  dis- 
covered by  Ducrey  (1899)  and  investigated  by  Krefting,  Unna, 
Xicolle,  etc.  This  bacillus  is  a  short  rod  with  rounded  extremities, 
which  appears  separately,  in  groups,  or  frequently  in  small  chains, 
whence  the  name  of  streptobacillus;  it  is  stained  with  carbol  blue, 
dilute  Ziehl's  solution,  etc.;  it  is  Gram-negative;  often  only  its  two 
extremities  take  the  stain.  Its  culture  requires  special  conditions 
and  was  for  the  first  time  successfully  obtained  by  Langlet  on  a 
medium  made  of  peptonized  human  skin;  Besancon,  Griffon  and 
Le  Sourd  obtained  cultures  on  blood-agar.  The  streptobacillus  can 
be  inoculated  into  various  species  of  apes.  It  possesses  a  striking 
resemblance  to  the  bacillus  of  bubonic  plague. 

Soft  chancre  almost  invariably  results  from  direct  venereal  con- 
tagion, through  the  deposit  of  chancroid  pus  on  some  traumatic  or 
pathological  erosion  during  sexual  intercourse;  more  rarely  it  is 
derived  from  an  indirect  contagion. 

The  frequency  of  soft  chancres  in  the  same  country  or  the  same 
city  is  subject  to  very  considerable  fluctuations.  A  preceding 
attack  confers  no  immunity,  as  illustrated  by  countless  positive 
inoculations  which  have  been  obtained  on  the  same  individual.  At 
the  time  when  the  single  or  dual  character  of  chancre  virus  was  still 
a  matter  of  controversy,  erroneous  hopes  were  entertained  of  a 
possible  vaccination  against  syphilis  by  means  of  this  so-called 
syphilization  method. 


SOFT  CHANCRE  597 

The  bacillus  grows  at  the  site  of  the  infection,  or  inoculation  for 
diagnostic  purposes  in  doubtful  cases,  the  lesions  developing  without 
any  incubation,  they  are  already  characteristic  at  the  end  of  twenty- 
four  or  forty-eight  hours  or  three  days  at  most. 

An  incipient  chancre  presents  the  appearance  of  a  vesicopustule 
with  an  inflammatory  areola;  on  removal  of  its  covering,  a  conical 
ulceration  is  exposed  which  penetrates  deeply  into  the  cutis.  Spon- 
taneous auto-inoculations,  notably  on  the  labia  majora  and  in  the 
intergluteal  fold  often  manifest  themselves  as  small  perifollicular 
pustules  which  have  been  named  chancroidal  folliculitis  or  miliary 
chancres. 

Papular  chancre  is  a  rare  variety,  but  useful  to  know;  it  appears 
as  a  flattened  or  slightly  acuminate  papule  with  a  soft  base. 
Papular  chancres  are  often  multiple  and  may  disappear  after  a  short 
time,  or  they  may  become  crested  with  a  vesicopustule  followed  by 
ulceration.  In  the  folds  of  the  vulva  and  anus,  simple  chancres  may 
assume  the  form  of  ulcerative  and  suppurating  fissures. 

The  mature  chancre  (p.  281)  rarely  attains  or  exceeds  the  size 
of  a  5-cent  piece.  At  the  end  of  a  period  varying  from  two  to  six 
weeks,  it  loses  its  virulence,  discharges  less  abundantly,  granulates 
and  heals  spontaneously.  Exceptionally,  soft  chancres  are  met  with 
which  persist  several  months  without  progressing  and  seem  to  be  of 
attenuated  virulence  although  still  capable  of  auto-inoculation. 
Soft  chancre  always  leaves  a  cicatrix  with  sinuous  outlines,  which 
may  be  smooth  or  honeycombed. 

No  general  disturbances  from  chancroidal  infection  are  known, 
the  disease  being  purely  local.  However,  various  complications 
may  occur.  The  most  common  of  these  is  suppurating  chancroidal 
bubo;  walking,  fatigue  and  absence  of  local  cleanliness  are  predis- 
posing factors.  From  the  onset,  during  the  course,  or  even  after 
cicatrization  of  the  chancre,  the  corresponding  gland  becomes 
swollen,  the  tissues  are  congested,  fluctuation  may  appear  and  unless 
treated,  spontaneous  rupture  takes  place  through  a  dark  red  and 
thinned  skin.  The  pus  of  this  bubo,  contrary  to  the  view  of  Straus, 
is  virulent  from  the  beginning  and  contains  the  bacillus.  Sponta- 
neous ulceration  of  a  bubo  ordinarily  assumes  a  chancroidal  character, 
that  is,  the  skin  becomes  detached  and  sinuous  burrows  as  well  as 
secondary  fistulas  are  formed.  This  likewise  occurs,  although  less 
frequently,  in  case  of  surgical  incision. 

Gangrene  of  the  prepuce  and  a  portion  of  the  sheath  of  the  penis 
is  occasionally  observed  in  the  course  of  subpreputial  chancres. 

At  the  anus,  soft  chancre  generally  gives  rise  to  an  elevated  con- 
dyloma (chancre  in  the  form  of  pages  of  a  book) ;  it  may  invade  the 
anal  canal  (chancroidal  anitis  of  Ravaut  and  Bord,  1909),  causing 
painful  and  bloody  stools. 

Phagedena  is  a  rare  but  formidable  complication  (p.  293). 


598  INFECTIOUS  BAClLLARY  DERMATOSES 

Histology  shows  soft  chancres  to  consist  of  a  loss  of  substance  of 
the  epidermis  and  the  cutis;  it  is  covered  with  a  layer  of  pus  contain- 
ing streptobacilli;  it  presents  radiating  processes  which  fissure  the 
floor  and  the  borders.  Beyond  this  layer  is  a  dense  infiltration  of 
well  developed  plasma  cells.  The  bloodvessels  show  very  pro- 
nounced changes  of  endoperivasculitis.  The  lymphatics  are  dilated. 
The  ulceration  results  from  a  sort  of  digestion  of  the  tissues  under 
the  influence  of  the  parasite. 

If  the  treatment  of  soft  chancre  is  to  he  efficient,  it  must  not 
be  limited  to  applying  a  little  iodoform  or  a  caustic  agent  to  its 
surface.  The  ulcer  must  first  be  cleansed  every  day  and  carefully 
dressed;  this  is  accomplished  by  means  of  cotton  wipes  or  rolls 
dipped  in  soapy  water,  alcohol,  or  benzine  and  not  until  then 
is  the  alterative  topical  agent  to  be  applied.  The  best  is  iodoform 
as  a  powder  or  iodoform  with  an  addition  of  camphor  (2  to  5 
per  cent.);  it  rarely  causes  dermatitis  provided  care  be  taken  to 
deposit  it  only  in  the  ulceration  itself;  its  persistent  and  suggestive 
odor  has  led  many  physicians  to  employ  substitutes  (iodol,  diiodo- 
form,  aristol,  europhen,  airol,  etc.),  but  none  is  so  efficient.  The  odor 
of  iodoform  can  be  concealed  to  some  extent  by  an  addition  of 
coumarin  or  even  of  powdered  roasted  coffee  beans.  Almost  equally 
valuable  is  silver  nitrate  in  aqueous  solution  (1  to  15),  in  customary 
usage;  or  pure  liquid  carbolic  acid  which  may  be  used  only  with 
extreme  caution;  carbolic  acid  has  also  been  recommended,  in 
alcoholic  solution  (10  per  cent.),  as  well  as  ferropotassic  tartrate 
(15  per  cent.)  and  potassium  permanganate  (from  2  to  4  per  cent.). 
The  borohypochlorite  powder  of  Vincent  seems  to  be  greatly  supe- 
rior.   A  small  cotton  dressing  must  be  applied. 

The  virulence  of  the  streptobacillus  is  destroyed  by  heat,  so  that 
very  hot  local  baths  should  be  prescribed,  to  be  repeated  at  least 
two  or  three  times  a  day,  or  preputial  irrigations,  or  continuous 
applications  of  compresses  soaked  in  hot  boiled  water  (42°  to  45°). 
Audry  recommends  the  employment  of  radiant  heat  of  the  thermo- 
cautery brought  within  a  few  millimeters  of  the  ulceration  until  its 
surface  is  dried  out.  A  superheated  air  apparatus  is  still  more  con- 
venient. This  procedure,  which  should  be  carried  out  two  or  three 
times,  is  somewhat  painful  but  very  effective. 

Suppurating  chancroidal  bubos  are  sometimes  aborted  under  the 
influence  of  rest  in  bed,  hot  compresses  and  compression  bandages. 
In  case  rupture  appears  inevitable,  a  careful  incision  may  be  made  or, 
better,  filiform  drainage  with  two  threads  established;  irrigations  are 
applied  every  day  until  the  discharge  becomes  merely  serous,  using 
a  silver  nitrate  solution  (1  per  cent.)  or  a  suspension  of  iodoform. 
Chancre  of  the  anus  is  treated  by  means  of  wicks  covered  with  a 
layer  of  iodoform-vaseline. 


CHAPTER  XXVIII. 
DERMATOMYCOSES. 

The  name  of  dermatomycoses  must  be  reserved  for  diseases 
developing  in  the  skin  or  reaching  the  cutis  secondarily  and  caused 
by  vegetable  parasites  of  a  higher  order  in  the  scale  than  the  schizo- 
mycetes  or  bacteria.  I  separate  these  from  the  epidermomy  coses 
which  have  already  been  discussed  (Chapter  XXV). 

After  actinomycosis  (the  first  known  type  in  this  category)  and 
Madura  foot,  which  is  related  to  it,  the  investigations  of  American, 
French  and  German  observers  revealed  the  blastomycoses,  and 
finally  the  sporotrichoses,  discovered  in  America,  studied  more 
particularly  in  France  in  the  last  ten  years  and  found  in  nearly  all 
the  countries  of  the  earth. 

It  is  an  established  fact  that  the  place  occupied  by  the  mycotic 
infections  in  human  and  animal  pathology  is  decidedly  larger  than 
was  formerly  believed.  Their  knowledge  is  not  only  of  scientific 
interest  but  also  possesses  considerable  practical  and  therapeutic 
importance. 

The  clinical  manifestations  of  the  dermatomycoses  are  poly- 
morphous and  often  ambiguous;  laboratory  investigations,  notably 
cultures,  are  indispensable  for  a  positive  diagnosis  and  for  identifi- 
cation of  the  pathogenic  agent.  This  explains  why  our  acquisitions 
in  this  domain  are  of  relatively  recent  date  and  as  yet  incomplete. 
Moreover,  it  has  been  recognized  that  almost  identical  clinical 
pictures  may  be  produced  by  different  species,  while  inversely  para- 
sites of  the  same  group  give  rise  to  dissimilar  affections.  Accord- 
ingly there  is  no  conformity  between  the  pathology  and  the  botanical 
classification.  The  latter  is  moreover  still  in  the  tentative  stage  in 
regard  to  the  lower  fungi  and  not  definitely  established. 

The  following  according  to  E.  Pinoy  are  the  botanical  groups  from 
which  the  principal  dermatomycoses  are  derived: 

Nocardia  (actinomycoses,  mycetomas) ;  Cohnistreptothrix  (actino- 
mycosis); cryptococcus  (blastomycoses);  oidium  (blastomycoses); 
madurella  (mycetomas);  sporotrichum  (sporotrichoses);  sacchar- 
myces  (blastomycoses);  and  aspergillus  (mycetomas). 

ACTINOMYCOSIS. 

The  parasite  which  causes  so-called  "lumpy  jaw"  in  cattle,  known 
in  France  as  sarcoma  of  the  bovine  maxilla,  was  named  actinomyces 


000 


DERMATOMYCOSES 


by  Bollinger.  It  gives  rise  in  man  to  suppurating  neoplasms  and 
gummous  formations.  It  appears  in  the  pus  or  in  the  tissues  in  the 
form  of  yellow  granules,  from  TV  to  1  mm.  in  diameter,  opaque  and 
of  oily  consistence;  they  can  be  seen  with  the  naked  eye  in  pus  which 
has  been  crushed  between  two  glass  slides  or  diluted  with  water  in  a 
watch-glass.  These  granules  are  mulberry-shaped  and  composed 
of  a  fragmented  feltwork  of  mycelium  in  their  center  from  1  to  2  /x 
in  width  and  at  the  periphery  by  large  club-shaped  refractive 
swellings,  resulting  from  degeneration  of  the  filaments,  arranged  in 
contiguous  rays  (Fig.  170).  These  clubs  are  sometimes  absent. 
Unlike  the  mycelium,  thev  do  not  stain  by  the  Gram  method  and  are 


_sa_ 


Fig.  176. — Actinomyces  granule.     After  Pinoy,  Bull,  de  1'Inst.  Pasteur,  November 
15  and  30,  1913,  xi. 


not  present  in  the  cultures.  The  latter  show  that  two  distinct  species 
may  be  involved,  differing  in  their  cultures;  either  Nocardia  bovis, 
growing  readily,  aerobic,  not  inoculable  into  animals;  or  Cohni- 
streptothrix  Israeli,  anaerobic,  growing  with  difficulty  and  inoculable 
into  the  peritoneum  of  guinea-pigs  and  rabbits. 

Actinomyces  live  quite  abundantly  as  saprophytes  outside  of  the 
animal  tissues.  Alan  is  rarely  attacked  through  contagion  from 
herbivorous  animals;  as  a  rule  he  becomes  infected  in  the  same  way 
as  cattle,  notably  through  grains  of  cereals  which  have  wounded  the 
skin  or  the  mucous  membranes  or  been  carelessly  swallowed.  The 
habit  of  chewing  herbs  or  bits  of  straw  when  strolling  through  the 
fields  must  be  regarded  as  dangerous  from  this  point  of  view. 


ACTINOMYCOSIS 


601 


Actinomycosis  exists  in  all  countries.  In  France,  its  relative 
frequency  in  the  vicinity  of  Lyons  was  pointed  out  by  Poncet,  in  the 
region  of  Bordeaux  by  Petzes.  It  is  more  common  in  Germany  [and 
rather  rare  in  America]. 

Clinical  Forms. — Cutaneous  actinomycosis,  which  alone  is  here 
considered,  may  be  primary  or  secondary;  that  is,  the  skin  affords  the 
parasite  an  avenue  of  entrance  which  is  rare,  or  of  exit,  which  is 
frequent.  The  lesions  are  cervico-facial  in  at  least  two-thirds  of  the 
cases,  or  they  may  be  thoracic  or  abdominal,  or  located  at  the  anus 
or  on  the  extremities. 


Fig.  177. — Actinomycosis  of  the  cheek. 


At  the  onset  there  is  a  hypodermic  nodosity,  with  a  rose-colored, 
hardly  painful  deeply  adherent  surface;  the  center  of  the  mass 
promptly  softens  and  becomes  fluctuating;  the  purplish  skin  gives 
way  and  permits  the  escape  of  a  small  amount  of  purulent  or 
sanious  fluid,  containing  yellow  granules.  At  the  same  time,  other 
nodules  have  formed  nearby  which  collect  into  patches  and  follow 
the  same  course;  the  ulcerations  remain  fistulous  and  granulating. 
(Fig.  177). 

There  is  presumptive  evidence  of  actinomycosis  when  lesions 
presenting  the  following  clinical  features  are  encountered :  nodosity 


602  DERMA  TOM  YCO&M& 

followed  by  a  Conglomerate  tumor  of  woody  hardness,  often  deeply 
adherent,  with  a  purplish  surface,  containing  foci  of  a  slowly  gather- 
ing gummous  pus;  absence  of  corresponding  glandular  enlargement; 
tendency  of  the  newfonnation  to  invade  all  tissues  indiscriminately, 
the  muscles,  the  vessels  and  even  the  hones. 

These  characteristic  features  usually  suffice  for  the  differential 
diagnosis  from  dental  abscesses,  chancroids,  lupus  and  tubercu- 
losis verrucosa,  tuberculo-gummous  syphilides,  epithelioma,  sporo- 
trichosis, etc.  The  demonstration  of  the  yellow  granules  will  supph' 
the  necessary  confirmation.  Sero-agglutination  and  the  fixation  test 
have  yielded  results,  but  these  are  not  reliable. 

Pathological  Anatomy. — The  parasite  stimulates  leukocytosis  and 
proliferation  of  the  fixed  constituents  in  the  form  of  nodules.  The 
latter  are  accordingly  formed  in  their  center  of  an  actinomyces 
granule  in  an  amorphous  necrotic  zone,  often  surrounded  by  a 
wreath  of  giant  cells;  next  by  a  zone  of  plasma  or  epithelioid  cells;  at 
the  circumference  there  is  a  more  or  less  considerable  infiltration  of 
leukocytes  and  swollen  connective-tissue  cells  which  insinuates  itself 
between  the  connective-tissue  bundles.  The  last-mentioned  zone  is 
of  fibro-sarcomatous  appearance  and  of  a  hard  or  lardaceous  con- 
sistence.   The  vessels  are  often  intact. 

Treatment. — Medication  with  potassium  iodide,  introduced  by 
Thomassen,  has  markedly  improved  the  otherwise  very  gloomy 
prognosis  of  actinomycosis.  Failures  do  occur,  however.  The  cus- 
tomary dose  is  at  least  6  grams  daily;  Pinoy  recommends  in  addition 
a  salt-free  diet  and  multiple  deep  cauterization  of  the  lesions.  In 
recent  and  not  very  extensive  cases,  a  cure  may  be  obtained  in  a 
few  weeks.  Local  iodide  injections  are  also  administered.  Radio- 
therapy seemed  to  me  to  exert  an  evidently  favorable  effect. 

Long-standing,  deep  and  complicated  cases  require  daily  doses  of 
0  to  12  grams  of  iodide  and  moreover  the  surgical  removal  or  curet- 
ting of  the  foci. 

MYCETOMA  OR  MADURA  FOOT. 

This  disease,  which  is  endemic  in  India,  Western  Africa,  Morocco, 
etc.,  is  due  to  several  species  of  mucedinese,  which  penetrate  into  the 
organism  by  means  of  a  foreign  body  such  as  thorns  or  splinters  of 
wood,  especially  in  bare-foot  natives.  The  forms  of  nocardia, 
madurella  mycetomi  and  Tozeuri  have  been  recognized;  Ch.  Xicolle 
grew  cultures  of  an  aspergillus  inoculable  into  pigeons  (Pinoy).  An 
analogous  affection  has  been  observed  in  America. 

Beginning  on  the  sole  of  the  foot,  nodosities  make  their  appear- 
ance which  soften  and  discharge  a  sanious  fluid  containing  granules 
of  parasites;  these  granules  are  white,  red  or  black,  which  has  led  to 


BLASTOMYCOSES  603 

three  varieties  of  mycetoma  being  described.  They  consist  of  a 
mycelial  feltwork  without  clubs.  Through  the  growth  and  multi- 
plication of  the  nodes,  the  foot  becomes  deformed,  globular  and 
assumes  an  elephantiastic  appearance  while  covered  at  the  same 
time  with  bulla?  or  tubercles  and  hollowed  by  fistulous  tracts;  the 
leg  on  the  other  hand  becomes  wasted  and  atrophic.  The  glands 
are  rarely  enlarged. 

Iodide  is  not  particularly  successful  and  must  be  reinforced  by  a 
salt-free  diet  and  cauterizations.  The  condition  is  relieved  by  the 
hyperthermic  baths  advocated  by  Legrain.  Curative  treatment 
must  be  surgical. 

BLASTOMYCOSES. 

Under  this  heading  diseases  are  classified  which  are  due  either  to 
yeasts  or  saccharomycetes  or  to  parasites  belonging  to  other  botanical 
groups  but  which  under  certain  conditions  present  themselves  in  the 
form  of  proliferating  buds  like  the  yeasts;  the  exact  determination 
of  the  latter  has  not  always  been  possible. 

The  clinical  appearance  of  the  blastomycoses  is  very  polymor- 
phous. To  illustrate  these  cases,  I  shall  limit  myself  to  outlining 
the  symptomatology  of  two  of  the  best  known  types  of  the  disease : 

1.  Busse-Buschke  Type. — This  extremely  rare  type  was  very  thor- 
oughly investigated  and  described  by  the  authors  whose  names  it 
bears;  the  cases  of  Ormsby-Miller,  Curtis  and  Hudelo  are  appar- 
ently closely  related  to  it.  The  pathogenic  agent  is  probably  a 
saccharomyees. 

The  condition  at  the  onset  is  marked  by  osseous  and  articular 
lesions;  later  on,  or  sometimes  from  the  start,  follicular  inflammations 
develop  or  more  often  disseminated  gummous  nodules  which  become 
transformed  into  ulcers;  their  purulent  contents  and  fungosities 
contain  yeasts  capable  of  cultivation  and  inoculation.  The  disease 
is  febrile,  taking  a  rather  rapid  course;  the  general  health  is  gravely 
impaired.    Death  results  from  glandular  and  visceral  lesions,. 

2.  Gilchrist  Type. — This  form  is  said  to  be  less  uncommon;  it 
was  pointed  out  by  Wernicke  (1892),  then  by  Gilchrist  and  Ricketts 
(1896)  and  was  at  first  attributed  to  protozoa.  About  forty  observa- 
tions have  been  published,  the  majority  in  America  (Hyde,  Mont- 
gomery, Stelwagon,  etc.),  and  only  five  or  six  in  Europe.  The  name 
of  blastomycetic  dermatitis  is  often  applied  to  it.  These  dermatitides 
are  due  to  two  parasites  which  present  a  different  appearance  in  the 
sections :  an  oidium  Gilchristi  in  form  of  a  yeast  and  a  parasite  with 
multiple  external  buds,  coccidioides  immitis. 

The  lesions  are  dermic  and  begin  on  one  of  the  extremities  or  on  the 
face.     A  hard,  reddish,  superficial  nodule  becomes  crusted  with  a 


604 


DERMATOMYCOSES 


yellow  point  and  is  transformed  into  a  pustule  discharging  a  thick 
viscid  pus.  The  miliary  abscesses  increase  in  number,  extend  and 
give  rise  to  an  irregular,  circumscribed  papillomatous,  erosive  patch, 
infiltrated  but  movable  on  the  deeper  layers.  The  vegetating  sur- 
face is  interspersed  with  miliary  abscesses,  sometimes  covered  with 
crusts  and  may  become  partially  cicatrized.  The  lesion  extends 
superficially  and  the  foci  often  multiply.  The  duration  has  fre- 
quently been  from  two  to  three  years  or  longer.  Spontaneous  cure 
may  occur  (  Figs.  ITS  and  179). 


^ 

jj 

■    >sp 

mm 

Fi< 


Fig.  178  Fig.  179 

178  and  179. — Clinical  types  of  cutaneous  blastomycosis.     (Ormsby.) 


Etiology.  Without  being  as  rare  in  Europe  and  notably  in  France 
as  was  formerly  assumed,  the  various  blastomycoses  are  nevertheless 
of  very  infrequent  occurrence.  In  the  lesions  the  parasites  are  seen 
as  rounded  bodies,  measuring  about  10/z,  composed  of  a  membrane 
with  double  contours  and  granular  contents.  They  are  more  or  less 
abundant  in  the  sections  and  may  be  stained  by  the  Gram-Weigert 
or  other  methods.  Pus-smears  should  be  washed  in  ether  and 
examined  in  a  solution  of  potash. 

The  cultures  in  some  cases  grow  readily  on  various  media,  notably 
on  peptone-agar  with  glucose  or  maltose,  preferably  in  the  incu- 
bator; in  other  cases,  they  are  only  obtained  with  difficulty  (Gil- 
christ type).  The  appearance  of  the  colonies  is  variable  and  not 
very  characteristic.  The  saccharomyces  remain  in  the  state  of 
spherical  or  budding  bodies  of  2  jx  to  20 fj,  diameter;  the  oidia  form 
mycelial-filaments  in  their  cultures. 

Inoculation  of  some  yeasts  is  successful  in  mice,  young  guinea- 
pigs  and  sometimes  in  dogs,  yielding  a  sort  of  pseudotuberculosis. 


SPOROTRICHOSES  605 

Man  can  certainly  be  infected  through  the  skin  and  perhaps  also  in 
other  ways.  It  must  not  be  overlooked  that  various  species  of 
mucedinese  may  be  found  accidentally  on  the  skin  or  may  live  there 
as  saprophytes;  they  may  secondarily  infect  pathological  lesions  of 
various  kinds.  Great  caution  is  therefore  necessary  in  the  inter- 
pretation of  their  pathogenic  value. 

The  several  serodiagnostic  tests  which  have  been  tried  do  not 
yield  constant  or  altogether  reliable  results. 

Pathological  Anatomy. — In  the  first-named  clinical  type,  there 
exists  a  granulation-tissue  rich  in  vacuolated  giant  cells  packed  with 
parasites. 

In  the  pustulo-vegetative  type,  intra-epidermic  abscesses  are 
demonstrable  and  in  the  cutis  a  superficial  infiltration  is  seen  formed 
by  various  cells,  notably  plasmocytes  with  rare  giant  cells.  The 
proliferating  epidermis  sends  branching  proliferations  hollowed  by 
miliary  abscesses  into  the  depth  of  the  tissue.  In  a  general  way, 
the  appearance  resembles  both  tuberculosis  and  epithelioma.  The 
parasites  are  scattered  and  are  found  especially  in  the  abscesses. 

Diagnosis. — Vegetative  syphilides  are  less  irregular  in  form  and 
have  fewer  miliary  abscesses.  Papillary  epithelioma  has  a  hard 
consistence,  friable  proliferations  and  whitish  masses  formed  of 
epithelial  cells.  The  resemblance  to  tuberculosis  verrucosa  may  be 
perfect;  Gilchrist  described  his  case  as  pseudolupus  verrucosus. 
The  blastomycoses  are  perhaps  less  purplish  and  less  painful,  more 
extensive  and  with  more  numerous  foci. 

In  suspected  cases,  aside  from  examinations  of  the  pus,  biopsy 
and  cultures,  it  is  advisable  to  inoculate  guinea-pigs  for  the  discovery 
of  tuberculosis  and  to  perform  the  Wassermann  test  for  the  elimina- 
tion of  syphilis. 

Treatment. —  The  blastomycoses  are  grave  affections  requiring 
energetic  treatment.  Iodides  have  proved  remarkably  successful 
but  must  be  given  in  large  doses,  from  6  to  8  grams  daily  and  long 
continued.  Local  surgical  treatment  is  sometimes  imperative. 
Dressings  with  iodine  solutions  should  be  applied. 

SPOROTRICHOSES. 

The  sporotrichoses  are  by  far  the  most  frequent  dermatomy coses. 

For  the  first  reported  cases  credit  is  due  to  Schenk  (1899)  and 
Hektoen  and  Perkins  (1900) ;  but  for  our  knowledge  of  the  mycoses 
in  general  and  sporotrichosis  in  particular  in  all  its  forms  we  are 
indebted  mainly  to  French  contributions,  particularly  those  of 
de  Beurmann  with  Ramond  (1903)  and  especially  with  Gougerot 
(1906-1912)  whose  work  drew  attention  to  this  subject. 

The  sporotricha  are  mucedinese,  namely  lower  filamentous  fungi. 


606  DERMATOMYCOSES 

with  a  creeping,  regular,  branching,  partitioned  or  continuous 
mycelium  bearing  numerous  short  sporulated  branches.  The  spores, 
measuring  from  .'J  to  <»m  originate  separately  or  in  groups  of  two, 
either  on  the  filaments  or  more  abundantly  on  the  conidiophorous 
branches.  It  is  not  known  if  these  parasites  do  not  possess  higher 
fructification-forms. 

Among  the  pathogenic  species,  the  best  known  and  the  most 
frequent  is  the  sporotrichum  Beurmanni,  which  I  shall  utilize  as  the 
type,  the  sporotrichum  Schenckii  differing  from  it  in  its  faintly 
colored  or  white  cultures  and  various  other  features;  the  sporo- 
trichum Dori  is  readily  distinguished  from  it. 

The  culture  method  is  the  procedure  of  choice  for  the  demonstra- 
tion of  these  organisms;  the  technic  of  de  Beurmann  and  Gougerot 
is  simple  and  easy.  Streaks  of  the  pus  on  unsealed  peptone-glucose 
agar  tubes  at  room  temperature  yield  at  the  end  of  six  or  eight 
days  visible  cultures  which  by  the  twelfth  day  have  become  exuber- 
ant and  are  often  pure  from  the  start.  The  method  of  Gougerot, 
which  consists  in  dropping  some  of  the  pus  on  the  glass  of  the  tube 
or  on  the  border  of  the  agar,  often  permits  a  rapid  diagnosis,  in  two 
or  three  days,  by  the  demonstration  of  small  gray  filamentous  stars, 
visible  to  the  naked  eye,  or  with  the  microscope  through  the  culture 
tube;  incubated  at  98°  the  growth  is  less  abundant.  Other  culture- 
media,  notably  carrots  with  glycerine,  may  be  utilized.  The  whitish 
and  acuminate  colonies  gradually  turn  brown,  spread  out  and 
convolute  on  their  margins,  which  are  surrounded  by  a  flat,  finely 
radiating  areola.    These  chocolate-brown  cultures  are  characteristic. 

Inoculations  into  animals  have  yielded  inconstant  results;  the 
virulence  is  slight.  De  Beurmann  and  Gougerot  have  obtained 
systemic  infections;  mice  are  the  most  suitable  animals. 

The  portals  of  entry  in  man  escape  observation;  sometimes  a 
previous  traumatism  has  been  noted  at  the  affected  point;  infec- 
tion seems  to  occur  especially  by  way  of  the  mouth.  [A  laboratory 
worker  in  Chicago  was  accidently  infected  on  the  conjunctiva.] 

Symptoms. — The  sporotrichoses  are  in  the  highest  degree  syphiloid 
or  tuberculoid.  However,  their  tissue  and  their  pus  are  not  inocul- 
able  into  adult  guinea-pigs,  which  are  susceptible  to  tuberculosis; 
they  are  not  influenced  by  mercurial  treatment;  left  untreated,  they 
persist  and  multiply,  whereas  they  are  often  readily  curable  by  iodide 
t  reatment ;  finally,  they  contain  a  special  parasite.  This  combination 
of  features  suffices  for  their  recognition  as  a  distinct  entity. 

The  disease  is  extremely  polymorphous  in  its  manifestations;  the 
following  are  the  principal  clinical  types: 

I.  The  disseminated  gummems  form;  the  gummas  (p.  270)  maybe 
softened  but  not  ulcerated;  or  ulcerative,  ulcero-vegetative,  ecthy- 
matiform;  they  may  assume  to  the  highest  degree  a  syphiloid  or 


SPOROTRICHOSES  607 

tuberculoid  appearance;  or  in  other  cases  that  of  large  more  or  less 
multiple  abscesses. 

2.  Lymphangitic  form  (Fig.  180),  consisting  of  lesions  of  the  pre- 
ceding type  in  chain-like  arrangement  above  an  initial  "sporo- 
trichotic  chancre;"  this  form  is  encountered  especially  on  the  limbs 
and  sometimes  on  the  head. 

3.  Extracutaneous  forms,  affecting  the  bones,  the  synovial  mem- 
branes, the  testicles  and  the  viscera;  it  is  especially  useful  to  be 
familiar  with  primary  sporotrichotic  osteitis  which  has  been  not 
infrequently  observed,  for  example  on  the  calcaneum;  it  gives  rise 
to  bone-liquefying  abscesses  and  then  to  fistulas  with  secondary 
cutaneous  lesions. 


Fig.  180. — Sporotrichosis,  lymphangitic  form;  of  two  and  a  half  years'  standing; 
positive  culture;  cure  in  three  weeks  by  potassium  iodide. 


4.  Ulcerative  forms  of  the  mucous  membranes,  localized  in  the 
mouth  or  pharynx,  may  extend  to  the  base  of  the  tongue,  the  larynx 
and  the  trachea;  these  cases  are  rare  but  extremely  grave.  Sporo- 
trichotic ulcers  of  the  mucous  membranes  are  distinguished  by  their 
prominence,  their  dirty  yellowish-gray  color,  the  absence  of  false 
membranes  on  their  surface,  their  tendency  toward  diffusion  rather 
than  deep  destruction  and  mutilation. 

Sporotrichotic  cicatrices  resemble  those  of  syphilitic  or  tuber- 
culous ulcers;  their  borders  are  often  irregular  and  ragged,  some- 
times showing  loosely  joined  tongue-like  processes. 

Diagnosis. — The  clinical  picture  may  furnish  highly  suggestive 
evidence;  in  the  St.  Louis  Hospital,  sporotrichosis  is  usually  recog- 
nized at  first  sight.  The  diagnosis  is  based  on:  the  multiplicity 
and  polymorphism  of  the  lesions,  which  taken  as  a  whole  justify  a 
diagnosis  neither  of  tuberculosis  nor  of  syphilis;  their  more  acute 
course  than  that  of  the  cutaneous  tuberculoses;  the  viscid  whitish 
pus  which  escapes  from  the  softened  nodules;  the  inconstancy  of 


608  DERMATOMYCOSES 

glandular  enlargements;  and  the  preservation  of  good  general 
health. 

Two  scientific  diagnostic  procedures  are  available,  however, 
which  are  indispensable  in  doubtful  cases,  which  are  very  common: 
(1)  Culture,  which  requires  from  eight  to  twelve  days;  (2)  sporo- 
agglutination,  discovered  by  Widal  and  Abrami,  which  furnishes 
immediate  information;  it  is  of  value  only  when  positive  and  at  a 
very  high  ratio,  at  least  1  to  200.  The  serum  of  patients  suffering 
from  actinomycosis  or  thrush,  etc.,  may  also  agglutinate  a  sporo- 
trichum  culture,  but  at  a  greatly  lower  ratio. 

The  reactions  after  cutaneous  or  subcutaneous  injection  of  sporo- 
trichum  emulsion  may  confirm  the  diagnosis,  but  do  not  establish 
it  by  themselves  alone,  on  account  of  the  possibility  of  associated 
reactions  due  to  other  mycoses  or  even  to  the  presence  of  simple 
saprophitic  yeasts  in  the  patient's  throat.  It  goes  without  saying 
that  a  negative  Wassermann  reaction,  proving  the  probable  absence 
of  syphilis  and  the  negative  outcome  of  inoculation  of  diseased 
tissue  into  guinea-pigs,  showing  the  absence  of  the  Koch  bacillus, 
are  signs  indirectly  capable  of  corroborating  a  suspicion  of  mycosis, 
but  insufficient  for  the  determination  of  the  special  agent. 

Pathological  Anatomy. — The  histological  lesions  of  the  sporo- 
trichoses are  not  more  characteristic  than  their  clinical  appearance. 
They  consist  of  a  nodular  inflammation  with  a  suppurative  center. 

According  to  the  general  formula  of  Gougerot,  the  sporotrichotic 
nodule  is  formed  by  three  concentric  zones:  at  the  periphery  it  is 
syphiloid,  due  to  its  subacute  perivascular  inflammatory  character, 
with  inconstant  connective-tissue  reaction  and  mononucleosis  with 
plasmocytes;  the  middle  zone  is  tuberculoid,  through  its  epithelioid 
tubercles  arranged  around  giant  cells;  the  center  is  suppurative, 
with  polynuclear  and  macrophagic  cells.  The  majority  of  the 
tubercles  originate  from  a  proliferation  of  the  vascular  walls. 

One  must  not  expect  to  find  branching  and  spore-bearing  myce- 
lium in  the  sections  or  in  the  pus;  the  only  findings,  which  are  more- 
over not  constant,  are  short  filaments  or  rather  "  navicular"  bodies, 
free  or  contained  in  phagocytes. 

Prognosis  and  Treatment. — Left  untreated,  the  sporotrichoses 
persist  and  their  foci  increase  in  number.  Under  the  influence  of 
iodides  they  are  curable  in  the  vast  majority  of  the  cases  in  the  space 
of  a  fortnight  to  two  months.  The  non-ulcerated  forms  subside 
more  rapidly  than  the  others.  The  existence  of  a  tuberculous  or 
other  cachexia,  to  which  the  sporotrichosis  may  be  secondary,  of 
course  aggravates  the  prognosis.  The  case  observed  by  Letulle- 
Debre  [pharynx,  etc.]  terminated  in  death. 

Potassium  iodide  should  be  administered  in  daily  doses  of  5  or  6 
grams,  or  more  if  tolerated  by  the  patient;  it  is  advantageous  to 


SPOROTRICHOSES  609 

combine  with  it  a  salt-free  diet;  other  iodides  or  injections  of  iodized 
oil  may  be  utilized  as  substitutes  in  case  of  intolerance.  Locally, 
it  is  necessary  to  puncture  the  purulent  collections  and  to  inject 
them  with  a  1  per  cent,  iodo-iodide  solution;  the  ulcerations  should 
be  dressed  with  the  same  solution.  The  treatment  should  be  con- 
tinued even  after  an  apparent  cure  has  been  obtained  and  be  renewed 
on  the  slightest  threat  of  a  relapse. 


CHAPTER   XXIX. 
INFECTIOUS  DERMATOSES  DUE  TO  PROTOZOA. 

Up  to  a  few  years  ago  it  was  assumed  that  all  infectious  diseases 
were  caused  by  bacteria  or  by  lower  fungi  closely  related  to  the 
Schizomycetes;  those  in  which  the  organism  had  not  been  found 
were  attributed  to  unknown  bacteria. 

The  discovery  of  the  trypanosomiases,  then  of  the  parasite  of 
syphilis,  the  other  spirochetoses,  leishmanioses,  etc.,  has  opened  a 
new  chapter,  to  which  in  all  probability  additions  will  be  made  in 
the  near  future. 

SYPHILIS. 

Syphilis — lues  venerea,  pox — is  a  systemic  infectious  disease,  trans- 
missible by  contact  and  congenital,  due  to  the  Spirochete  pallida. 

It  is  extremely  contagious  and  consequently  very  widely  distrib- 
uted; it  may  affect  all  organs  and  all  tissues  without  exception; 
give  rise  to  symptoms  of  the  greatest  gravity  such  as  cerebral 
syphilis,  tabes,  general  paralysis,  etc. ;  and  be  followed  by  cancer  of 
the  mouth,  abortion  and  a  high  infantile  mortality.  Thus  it  is  only 
too  true  that  syphilis  is  one  of  the  greatest  scourges  of  the  human 
race. 

Infection  usually  takes  place  through  the  skin  or  through  the 
mucous  membranes  and  its  most  characteristic  manifestations  are 
exhibited  on  the  external  integument.  Their  description  must 
therefore  necessarily  figure  in  a  text-book  of  dermatology.  The 
general  picture  of  the  disease  will  be  given  only  in  brief  outline. 

Etiology. — In  May  of  1905,  T.  Schaudinn  and  E.  Hoffmann 
reported  the  discovery  in  the  contagious  lesions  of  syphilis  and  in 
the  lymph  glands,  of  a  parasite  which  seemed  to  be  the  long-sought 
causative  agent  of  this  disease.  This  has  been  definitely  established 
by  their  later  studies  and  by  innumerable  control  investigations. 
The  responsible  organism  had  been  seen  a  few  years  previously  in 
a  chancre,  by  Bordet  and  Gengou,  who  were  not  able,  however,  to 
follow  it  in  the  various  syphilitic  lesions. 

The  parasite  of  syphilis,  now  classified  under  the  name  of  Sjjiru- 
cheta  pallida  or  Treponema  pallidum  is  a  protozoon  of  spirillary 
form,  whose  cylindrical  body,  of  an  average  length  of  6  to  14  ju 
and  a  width  of  at  most  0.3yu,  describes  close-set  narrow  spirals,  from 
six  to  twenty  in  number;  it  terminates  at  both  ends  in  an  extremely 
slender  flagellum.     An  undulating  membrane  has  so  far  not  been 


SYPHILIS  611 

demonstrated.  Living  specimens  on  ultramicroscopical  examination 
are  seen  to  move  actively  for  several  hours.  Some  deviations  from 
this  typical  appearance  have  been  observed,  possibly  corresponding 
to  developmental  stages  in  a  still  unknown  evolution.  The  trepo- 
nema  for  a  long  time  was  refractory  to  culture  in  any  artificial 
culture-medium;  Schereschewsky,  W.  H.  Hoffmann,  Sowade, 
Noguchi  and  others  succeeded  in  growing  it  in  pure  culture  under 
special  conditions. 

The  agent  of  syphilis  can  be  stained  with  less  difficulty  than  was 
originally  believed.  It  is  readily  obtained  in  very  thin  smears  of 
serous  exudate  or  tissue-juice,  fixed  by  heat,  washed  repeatedly 
for  three  or  four  minutes  with  a  boiling  mixture  of  the  following 
composition:  To  9  c.c.  of  distilled  water  add  2  drops  of  a  1  per  cent, 
solution  of  potassium  carbonate,  and  2  drops  of  neutral  glycerine; 
heat  to  the  boiling-point  and  add  10  drops  of  Giemsa's  eosine-azure ; 
the  specimen  must  be  very  carefully  rinsed  in  running  water  before 
it  is  dried  and  examined.  Burri's  method  is  also  very  convenient: 
the  exudate  is  mixed  on  the  slide  with  a  small  drop  of  India  ink, 
spread  out  in  a  very  thin  layer,  allowed  to  dry  in  the  air  and  then 
directly  examined  in  immersion  oil ;  the  parasites  stand  out  white  on 
the  dark  background.  In  the  tissues  the  parasite  is  demonstrated 
by  means  of  the  silver  reduction  methods  devised  by  Levaditi. 

The  spirochetes  are  constantly  present  in  very  large  numbers  in 
the  chancre.  They  are  also  found  in  the  glands  and  in  great  abund- 
ance in  mucous  patches  and  recent  papules  of  all  kinds;  they  are 
less  frequent  in  the  roseolar  spots,  a  blister  produced  by  the  applica- 
tion of  a  fly-plaster  to  a  papule  often  contains  many  spirochetes. 
Spirochetes  have  been  found  in  the  spleen  (Schaudinn),  in  the  supra- 
renal capsules  (Jacquet  and  Sezary),  and  in  the  meninges.  Their 
usual  presence  in  the  blood  during  the  active  stages  of  the  disease 
has  often  been  demonstrated,  especially  indirectly;  in  the  cerebro- 
spinal fluid,  the  seminal  fluid,  the  milk  and  the  urine,  the  parasite 
of  syphilis  is  found  only  under  special  and  exceptional  conditions. 
They  are  very  rare  in  tertiary  lesions,  but  Noguchi  and  several 
investigators  after  him  found  spirochetes  in  the  brains  of  patients 
who  had  suffered  from  general  paralysis.  They  are  very  abundant 
in  children  and  fetuses  with  congenital  syphilis,  notably  in  the  liver, 
the  spleen,  the  suprarenals,  the  lungs,  the  blood,  as  well  as  in  the 
cutaneous  lesions.  The  parasite  has  been  successfully  followed  in 
serial  inoculation  into  monkeys  and  more  recently  also  other  animals. 

Syphilis  was  for  a  long  time  considered  as  absolutely  peculiar  to 
man;  it  was  taught  that  neither  race  nor  age  nor  sex  confer  immunity 
against  it,  but  that  a  first  attack  renders  the  patient  permanently 
immune.  More  recently  it  has  been  recognized,  however,  that  the 
immunity  acquired  by  a  first  infection  may  not  always  be  absolute 


612  INFECTIOUS  DERMATOSES  DUE  TO  PROTOZOA 

and  permanent;  the  possibility  of  reinfection  lias  been  demonstrated 
in  some  cases,  not  numerous  but  convincing. 

On  the  other  hand,  two  years  before  the  discovery  of  the  spiro- 
chete (July  28,  1903)  Roux  and  Metchnikoff  showed  that  syphilis 
is  inoculable  into  anthropoid  apes;  Lesser,  Xeisser  and  many  others 
confirmed  these  observations.  Since  that  time  it  has  been  recog- 
nized that  inoculation  is  also  successful  in  the  lower  monkeys;  an 
attempt  has  been  made  to  utilize  this  fact  for  diagnostic  purposes, 
a  procedure  which  actually  possesses  but  small  practical  value. 
More  recently  syphilis  has  been  successfully  inoculated  into  rabbits, 
dogs,  guinea-pigs  and  sheep.  Inoculation  into  the  rabbit's  cornea 
(Bertarelli)  or  on  the  scrotum  of  this  animal  (Parodi)  has  so  far 
yielded  most  positive  results;  their  proportion  is  increased  in  serial 
reinoculations  and  sometimes  symptoms  of  generalization  have  been 
noted.  Experimental  syphilis  has  already  led  to  valuable  scientific 
findings  and  is  sure  to  furnish  a  further  abundant  harvest. 

According  to  the  classical  teachings,  there  are  two  modes  of  con- 
tracting syphilis:  by  contagion  or  by  heredity. 

Acquired  syphilis  results  from  a  venereal  or  accidental  contact, 
which  may  be  direct  or  indirect;  congenital  syphilis  is  present  at 
the  birth  of  the  child  and  is  derived  from  its  parents. 

Acquired  Syphilis. — The  course  of  acquired  syphilis  is  subject  to 
certain  laws.  The  infecting  contact  is  followed  by  a  latent  period 
known  as  the  first  incubation,  usually  lasting  twenty-five  days, 
sometimes  shortened  to  ten  or  fifteen  days  or  very  exeeptionally 
prolonged  to  sixty  and  even  to  ninety  days.  Then  the  primary  mani- 
festation makes  its  appearance  at  the  point  of  the  inoculation  itself, 
as  the  syphilitic  chancre  with  which  at  the  end  of  about  a  week  a 
satellite  bubo  becomes  associated,  constituting  the  primary  stage. 

Next  follows  another  latent  period,  the  second  incubation,  of  an 
average  duration  of  forty-five  days,  at  the  end  of  which  the  secondary 
symptoms  appear;  these  are  of  various  forms,  scattered  and  profuse, 
usually  showing  a  benign  behavior  and  located  especially  on  the  skin 
and  the  mucous  membranes;  as  a  rule  they  recur  during  several 
months,  or  sometimes  during  two  or  three  years  or  longer  when  the 
disease  is  left  to  itself  or  is  insufficiently  treated. 

Later  on,  especially  after  the  fourth  year,  sometimes  earlier,  and 
often  at  remote  dates  of  ten,  twenty  or  thirty  years  or  still  later, 
the  tertiary  symptoms  may  appear.  While  they  have  less  tendency 
to  diffusion  than  the  secondary  symptoms,  they  cause  much  deeper 
damage  to  the  tissues  in  which  they  are  situated.  They  may  affect 
any  organ,  any  apparatus,  including  the  skin  and  the  mucous 
membranes  and  notably  the  nervous  system,  the  last-named  locali- 
zation being  especially  formidable, 


SYPHILIS  613 

The  primary  lesion,  the  chancre,  is  practically  never  absent,  but 
it  may  remain  undetected,  this  being  actually  frequent  in  women. 
The  few  known  cases  of  "immediate  syphilis"  (d'emblee)  or  "decapi- 
tated syphilis"  in  men  are  explained  by  very  unusual  conditions. 
In  the  absence  of  early  and  energetic  treatment,  the  secondary 
manifestations  are  only  very  rarely  absent.  This  remark  does  not 
apply  to  the  tertiary  symptoms,  which  develop  preferably  in  tainted, 
intoxicated  or  exhausted  individuals  under  bad  hygienic  conditions 
and  especially  in  incorrectly  or  insufficiently  treated  patients. 

It  is  noteworthy  that  the  secondary  and  tertiary  periods  are  not 
always  distinctly  separated,  neither  in  time  nor  by  the  character 
of  the  associated  manifestations,  but  may  widely  encroach  upon  one 
another  [or  overlap].  This  subdivision  is  nevertheless  justified  by 
the  course  of  the  majority  of  the  cases  and,  moreover,  is  convenient 
from  the  didactic  point  of  view. 

Syphilis  may  finally  eventuate  in  remote  sequelae  which  are  not 
influenced  by  antisyphilitic  treatment.  A.  Fournier  designated 
these  as  parasyphilitic  symptoms  and  interpreted  them  as  indirect 
consequences  of  syphilis.  This  group  (general  paralysis,  tabes, 
leukoplakia,  aneurysms,  etc.)  will  undoubtedly  have  to  be  rear- 
ranged, for  the  presence  of  spirochetes  in  the  brain  of  paretics  shows 
that  in  these  cases  at  least,  genuine  syphilis  is  responsible  [and  this 
is  certainly  true  also  for  tabes  and  aneurysm]. 

Among  all  the  symptoms  of  syphilis,  only  the  primary  chancre 
and  the  secondary  or  tertiary  lesions  involving  the  skin  and  the 
mucous  membranes  enter  into  the  scope  of  this  book.  These  sec- 
ondary and  tertiary  cutaneous  or  mucous  manifestations  are 
generally  designated  under  the  name  of  syphilides. 

Syphilitic  Chancre. — Also  known  as  hard  chancre  [ulcus  durum], 
primary  lesion,  initial  sclerosis.  The  syphilitic  chancre  develops  at 
the  point  which  has  served  as  the  infection-atrium  of  the  virus.  It 
suffices  that  living  treponemata  derived  from  a  contagious  syphilitic 
lesion  be  deposited  upon  a  traumatic  or  pathological  lesion,  ulcer- 
ation, herpetic  erosion,  fissure,  or  even  a  trifling  excoriation,  to 
bring  about  the  infection;  it  is  not  probable  that  they  can  pass 
through  the  intact  epidermis,  but  they  may  possibly  pass  through 
the  intact  epithelium  of  mucous  membranes.  Transmission  usually 
takes  place  directly,  through  sexual  intercourse,  kissing,  accidental 
or  occupational  contact;  much  less  commonly  through  the  inter- 
mediation of  some  contaminated  object. 

During  the  first  incubation,  the  lesion  which  has  served  as  the 
infection-atrium  has  usually  had  ample  time  to  disappear.  The 
parasite  multiplies  locally  at  first  without  producing  a  demon- 
strable reaction  and  already  begins  to  spread  in  the  organism 
through  the  lymphatics  and  the  veins;  indeed,  an  early  excision 


fil4 


INFECTIOUS  DERMATOSES  DUE  TO  PROTOZOA 


of  the  incipient  chancre,  for  the  purpose  of  aborting  the  syphilis 
is  almost  invariably  unsuccessful.  The  production  of  immunity 
is  not  immediate,  however;  the  chancre  is  often  auto-inoculable 
during  the  first  eleven  days  following  its  appearance,  according  to 
Queyrat;  this  would  serve  to  explain  the  cases  of  successive  multiple 
chancres. 

An  incipient  chancre,  better  known  through  experimentation 
on  monkeys,  presents  the  appearance  of  a  very  small  slightly 
papular  red  spot,  or  in  other  cases  a  scaly  crust  covering  a  super- 
ficial erosion.  The  erosion  and  induration  keep  on  progressing  until 
in  a  few  days  the  primary  sore  (Fig.  181)  has  assumed  the  six  follow- 
ing characteristics,  as  clearly  pointed  out  by  A.  Fournier: 


Fig.   181. — Syphilitic  chancre  of  the  sheath  of  the  penis,  of  five  weeks'  standing; 
untreated. 


(1)  It  is  a  slight  erosion,  generally  of  the  size  of  a  dime  [about 
1  cm.],  not  an  ulceration;  (2)  it  has  a  round,  regular,  orbicular 
form;  (3)  without  marked  borders,  that  is,  without  prominence, 
perpendicular  depression  or  detachment,  its  surface  being  on  the 
same  level  as  the  surrounding  tissues  or  sometimes  slightly  convex 
or  depressed;  (4)  of  a  color  varying  from  red,  flesh-color  with 
smooth,  moist  and  glazed  or  finely  granular  surface,  to  a  grayish 
color  with  diphtheroid  surface  scattered  with  ecchymotic  points  and 
sometimes  covered  with  a  thin  brownish  crust;  (5)  an  indurated 
base,  which  is  recognized  by  grasping  the  chancre  between  the 
thumb  and  index  finger,  across  its  diameter  and  slightly  raising  it; 
thereby  demonstrating  a  characteristic,  circumscribed  and  dry 
hardness,  of  very  variable  thickness,  sometimes  superficial,  like 
parchment  or  paper,  in  other  cases  deep,  resembling  pasteboard,  or 
nodular;  (0)  the  chancre  is  accompanied  by  a  satellite  bubo. 

This  bubo,  which  according  to  Ricord's  expression  follows  the 


SYPHILIS  615 

chancre  as  the  shadow  follows  the  body,  has  its  seat  in  the  glands 
corresponding  to  the  lymphatic  territory  of  the  chancre.  It  con- 
sists of  a  glandular  constellation,  namely  a  group  of  hard,  ovoid, 
movable,  painless  and  non-inflammatory  glands;  one  or  two  of 
these  glands  are  apt  to  be  larger  than  the  rest  and  may  present  a 
very  evident  protuberance.  The  bubo  appears  from  six  to  ten  days 
after  the  chancre  and  survives  it  as  a  posthumous  witness  for  a 
number  of  months. 

The  chancre  itself  heals  in  a  fortnight  to  six  weeks;  the  induration 
as  a  rule  persists  for  several  months,  sometimes  actually  increasing; 
a  cicatrix  is  seen  in  only  about  one-half  of  the  cases. 

Exceptionally,  an  erosion  known  as  chancre  redux  may  reappear 
at  the  same  point,  after  a  very  variable  period. 

The  varieties  of  syphilitic  chancre  are  innumerable;  but  the 
typical  form  is  by  far  the  most  common. 

There  occur  dwarf  lenticular  chancres,  or  giant  chancres;  papular, 
hypertrophic,  or  markedly  ulcerative  chancres,  or  echthymatous 
chancres  covered  with  a  fairly  thick  crust.  Although  hard  chancre 
is,  as  a  rule,  solitary,  multiple  chancres  to  the  number  of  two  or  three, 
or  more,  are  encountered  nearly  as  frequently  and  up  to  fourteen 
have  been  counted  on  the  same  patient;  they  are  simultaneous  or 
successive,  which  may  be  due  to  a  variable  incubation,  successive 
contaminations,  early  auto-inoculations,  or  to  a  chancrous  lymphan- 
gitis which  has  given  rise  to  local  erosions. 

Complications. — The  onset  of  the  chancre  may  be  directly  pre- 
ceded by  a  herpetic  eruption,  a  common  and  serious  source  of  error; 
this  herpes  runs  the  ordinary  course,  but  one  or  several  of  the  ero- 
sions become  indurated,  thereby  revealing  their  chancrous  character. 
The  chancre  is  not  uncommonly  accompanied  by  a  local  and  vo- 
luminous first  soft  then  hard  sclerotic  edema,  notably  of  the  vulva 
or  the  prepuce  (phimosis),  which  suggests  its  presence,  although  it 
helps  to  conceal  it;  the  chancrous  induration  can  be  felt  with  the 
finger  and  confirms  the  diagnosis.  The  indurated  chancre  becom  3S 
inflamed  after  traumatism,  improper  treatment  or  secondary 
infection;  it  becomes  painful,  bleeds  and  suppurates;  sometimes, 
the  bubo  itself  undergoes  a  usually  sluggish  purulent  disinte- 
gration. Superficial  or  penetrating  gangrene  and  phagedena  are 
rare  complications.  Mixed  chancre,  propounded  by  Rollet  (Lyon) 
is  more  or  less  rare  according  to  the  environment  and  results  from 
inoculation  at  the  same  point  with  the  Ducrey  bacillus  and  the 
treponema,  their  incubation  being  of  very  unequal  length.  When 
the  infections  are  simultaneous,  a  soft  chancre  develops,  then 
becomes  indurated  and  opens  again  in  case  it  was  cicatrized;  when 
the  infection  is  successive,  a  soft  chancre  becoming  grafted  on  a 
syphilitic  chancre,  it  forms  an  ulcer  in  the  preexisting  induration. 


616  INFECTIOUS   DERMATOSES  DUE  TO  PROTOZOA 

Localization. —  Genital  chancre  in  men  is  more  frequently  located 
in  the  balanoprepntial  groove  and  the  sides  of  the  frenum,  but  may 
occur  on  any  other  point  of  the  penis,  the  scrotum  or  the  pubis. 
Chancre  of  the  meatus  and  intra-nrethral  chancre,  which  are  rare, 
manifest  themselves  by  a  serous  oozing  and  a  circumscribed  indura- 
tion. In  women,  the  labia  majora  and  minora,  the  fourchette,  the 
<lit  oris,  and  more  rarely  the  meatus,  are  the  seat  of  the  chancre;  hardly 
ever  the  vagina.  (  hancre  of  the  uterine  cervix  would  appear  less  rare 
if  it  were  more  frequently  looked  for;  it  presents  itself  in  the  form 
of  a  distinctly  limited  red  or  grayish  erosion  with  a  narrow  red 
margin  and  an  induration  perceptible  to  the  touch.  [In  rare  cases 
it  may  become  the  site  of  cauliflower  excrescences  on  the  cervix.] 

Extragenital  chancre  is  localized  on  the  head  in  two-thirds  of  the 
eases,  preferably  at  the  mouth  and  especially  on  the  lower  lip;  when 
it  straddles  the  free  borders  of  the  lip,  it  is  crusted  in  its  cutaneous 
portion,  erosive  in  its  mucous  portion.  After  chancre  of  the  lips 
come  in  order  of  frequency,  chancre  of  the  tongue  and  chancre  of  the 
tonsils.  The  latter,  which  must  not  be  confused  with  angina,  nor 
especially  with  the  fusospirillary  ulceration  of  Vincent,  is  unilateral, 
erosive  or  ulcerative,  nearly  always  diphtheroid,  of  woody  hardness 
to  the  touch,  gives  rise  to  only  slight  pain,  persists  during  four  or 
five  weeks  and  is  associated  with  a  usually  enormous  enlargement 
of  the  retromaxillary  glands.  Chancres  of  the  chin,  the  eyelids,  the 
conjunctiva,  the  nostrils,  the  gums,  the  scalp,  etc.,  present  no  very 
specific  features;  [the  associated  adenopathy  usually  creates  a 
suspicion  of  their  nature]. 

On  the  upper  limbs,  chancre  affects  chiefly  the  fingers,  the  cir- 
cumference of  the  nails  or  the  joints;  it  resembles  a  badly  healing 
panaritium  or  a  proliferating  wound.  This  localization  is  not  uncom- 
mon in  physicians  and  midwives  and  the  same  is  true  for  chancres 
of  the  eye.  Vaccination  chancre  has  become  extremely  rare  since 
vaccination  from  arm  to  arm  has  been  generally  abandoned. 

Chancre  is  also  frequently  situated  on  the  breast,  notably  in 
wet  nurses. 

It  is  fairly  common  at  the  anus  in  both  sexes  and  is  here  apt  to 
assume  the  so-called  book-leaf  form.  There  is  no  region  of  the  body 
in  which  its  occurrence  has  not  been  noted. 

Extragenital  chancres  are  usually  the  beginning  of  innocently 
acquired  infections,  syphilis  insontium,  comprising  occupational 
syphilis,  workshop  epidemics  (glass-blowers,  for  example),  family 
epidemics  and  so  forth. 

The  frequency  of  extragenital  chancres  as  compared  to  that  of 
genital  chancres  is  in  the  proportion  of  1  in  8  or  9.  The  possibility 
of  this  occurrence  must  always  be  kept  in  mind  so  as  to  guard 
against  error,  which  may  have  very  serious  sequela?. 


SYPHILIS  617 

Diagnosis. — In  some  cases  the  diagnosis  of  syphilitic  chancre  is 
evident  from  the  start;  in  others,  the  objective  features  of  the  lesion 
merely  justify  a  suspicion  which  requires  to  be  confirmed;  it  is  well 
to  remember  the  possibility  of  chancre  no  matter  what  may  be  the 
patient's  social  standing  or  age  or  the  seat  of  the  suspicious  lesion 
(extragenital  chancres) . 

Even  when  the  diagnosis  is  certain,  it  is  advisable  for  reasons 
readily  understood,  to  state  the  truth  only  guardedly  and  with  the 
greatest  circumspection  to  the  patient.  Where  there  is  the  least 
doubt,  and  in  fact  in  all  cases,  it  is  important  to  control  the  objective 
diagnosis  by  what  may  be  called  the  elements  of  the  general  diag- 
nosis of  syphilis  and  especially  by  laboratory  investigations.  It 
would  be  a  serious  error  to  begin  specific  treatment  before  having 
absolutely  proved  of  the  existence  of  syphilis. 

The  history,  statements  of  a  suspicious  contact  three  or  four 
weeks  before  the  appearance  of  the  chancre  and  confrontation  in 
certain  cases,  possess  only  the  value  of  highly  probable  arguments. 

The  best  and  most  practical  procedure  for  scientific  demon- 
stration consists  in  the  ultra-microscopical  examination  of  the  serous 
fluid  which  has  been  squeezed  out  of  the  chancre  after  superficial 
scraping. 

For  this  examination  to  be  valid,  the  patient  must  not  yet  have 
received  specific  treatment  and  no  antiseptic  or  caustic  application 
of  any  kind  must  have  been  locally  employed  in  the  last  five  or  six 
days.  The  discovery  of  the  characteristic  spirochetes  is  conclusive; 
in  case  of  failure,  the  examination  should  be  repeated  after  a  few 
days'  interval  [or  should  be  repeated  daily  if  necessary,  the  patient 
meanwhile  covering  the  lesion  with  a  moist  dressing  of  normal 
saline  solution]. 

The  Wassermann  reaction  does  not  become  positive  until  about 
the  eighteenth  day  of  the  chancre. 

In  Chapter  XV  {'passim)  may  be  found  the  essentials  of  the  differ- 
ential diagnosis  of  hard  chancre  and  other  analogous  ulcerations. 
Briefly  stated,  the  lesions  of  the  genital  region  which  most  frequently 
lead  to  confusion  with  a  primary  sore  are  the  following: 

Traumatic  ulcerations  are  of  more  irregular  form,  non-indurated, 
without  bubo. 

Herpes  may  mask  an  incipient  chancre  and  must  be  watched; 
when  it  has  been  cauterized,  treated  with  an  irritative  lotion, 
for  example  with  perchloride  of  mercury,  or  with  certain  powders 
such  as  aristol,  the  herpetic  erosion  hardens,  the  glands  become 
swollen  and  the  aspect  may  be  to  the  highest  degree  suggestive  of 
chancre.  After  several  days  when  the  inflammation  has  subsided 
under  the  influence  of  rest,  baths  and  moist  dressings,  the  artificially 
induced  difficulty  will  generally  have  disappeared;  if  necessary,  an 
ultramicroscopic  examination  can  be  carried  out. 


liiS  INFECTIOUS  DERMATOSES  DUE  TO  PROTOZOA 

Soft  chancre,  with  its  perpendicular  borders  and  its  irregular  and 
suppurating  Moor,  rarely  causes  difficulties;  all  doubts  can  be  settled 
in  forty-eight  hours  at  most,  by  the  discovery  of  the  I  hicrey  bacillus, 
or  better  by  auto-inoculation  in  the  deltoid  region.  In  case  of  mixed 
chancre,  this  auto-inoculation  would  be  positive  and  the  discovery 
of  the  spirochete  practically  impossible;  under  these  difficult  con- 
ditions, the  appearance  of  a  positive  serum  reaction  often  becomes 
the  only  practical  way  of  settling  the  diagnosis. 

The  name  of  chancriform  syphiloma  is  applied  to  a  lesion  which 
may  appear  between  the  second  and  the  fifth  year,  preferably  at  the 
point  where  the  original  chancre  was  located,  the  features  of  which 
it  may  closely  reproduce;  or  it  may  be  more  irregular  in  contour  and 
deeper.  In  all  cases,  there  is  no  bubo,  the  Wassermann  reaction  is 
positive  from  the  start  and  the  antecedents  are  sufficient  to  post  the 
physician.  The  interest  of  this  manifestation  lies  in  its  frequently 
having  given  rise  to  the  suspicion  of  a  reinfection;  it  has  been 
thought  that  it  might  sometimes  be  the  result  of  a  specific  rein- 
oculation  on  an  imperfectly  immunized  territory. 

The  treatment  of  syphilitic  chancre  must  be  very  simple;  it  is 
essential  to  avoid  all  irritation. 

Early  excision  under  certain  conditions  still  has  its  adherents;  it 
will  be  discussed  further  on. 

Cauterizations,  applications  of  mercurial,  calomel,  iodoform,  etc., 
salves  should  be  avoided;  clean  moist  dressings,  with  glycerolated 
starch  or  borated  vaseline  are  sufficient. 

Under  the  influence  of  energetic  general  treatment,  a  chancre  will 
heal  in  less  than  ten  days. 

Second  art/  Stage. — From  thirty-five  to  sixty  days  after  the  appear- 
ance of  the  chancre,  generally  at  the  end  of  forty-five  days,  the 
secondary  symptoms  develop.  These  are  sometimes  multiple, 
profuse  and  stormy,  such  cases  being  described  as  secondary  ex- 
plosions. All  possible  degrees  may  occur  between  the  nearly  com- 
plete absence  of  all  manifestations  and  the  forms  described  as 
precocious  malignant  syphilis. 

The  secondary  lesions  may  affect  a  large  number  of  organs  or 
organic  systems.    Generalized  glandular  enlargement  is  never  absent.1 

Roseola,  papular  eruptions,  mucous  patches  and  headache,  are 

1  The  generalized  adenopathy  becomes  progressively  established  in  the  course  of  the 
primary  stage.  In  case  of  chancre  of  the  genital  region,  the  inguinal  bubo  appears 
from  the  ninth  to  tenth  day  after  chancre;  the  cervical,  supraclavicular,  middle  and 
suboccipital  glands  become  perceptible  to  touch  by  the  twelfth  to  fifteenth  day; 
the  cpitrochlear  glands  toward  the  eighteenth  day.  The  value  of  the  presence  or 
absence  of  generalized  glandular  enlargement  for  the  diagnosis  of  syphilis  is  con- 
siderable and  too  often  overlooked;  I  have  emphasized  its  importance  for  many  years 
in  my  hospital  service. 


SYPHILIS  619 

extremely  common ;  neuralgias,  myalgias,  arthralgias,  deep  bone-pains 
are  frequent;  alopecia,  iritis,  albuminuria,  abortion,  are  not  rare. 

The  general  condition  is  more  or  less  disturbed;  there  often  is  an 
anemic  pallor,  with  rather  marked  leukocytosis;  loss  of  strength, 
anorexia,  emaciation,  neurasthenia,  enlargement  of  the  spleen. 

In  women  especially,  fever  with  an  irregular  course  may  be 
observed;  a  typhoidal  state  ("typhose  syphilitique")  has  even 
been  described  but  such  cases  are  probably  due  to  superadded  infec- 
tions. [In  exceptional  cases  the  temperature  may  reach  or  exceed 
104°  F.  (40°  C,)]. 

These  various  secondary  manifestations  may  becomes  endlessly 
combined,  their  coincidence  often  facilitating  the  diagnosis.  How- 
ever, in  a  fair  number  of  cases  the  cutaneo-mucous  eruptions  or 
secondary  syphilides  which  are  alone  to  be  described  in  this  book, 
present  themselves  separately  without  other  symptoms  besides 
generalized  glandular  swelling. 

Secondary  Syphilides. — Their  general  features  are  their  poly- 
morphism, their  abundance,  their  dissemination,  their  insidious 
non-inflammatory  development,  their  painlessness  and  the  complete 
absence  of  itching. 

The  lesions  are  usually  of  a  rounded  form,  sometimes  arranged  in 
rings,  loops  or  clusters  (See  Fig.  39  and  127) ;  their  color  is  yellowish- 
red,  like  bacon,  sometimes  coppery,  or  of  a  so-called  sombre  hue. 
A  development  in  successive  crops,  a  tendency  to  spontaneous  invo- 
lution and  frequent  recurrences  complete  their  general  properties. 

The  eruptive  lesions  of  secondary  syphilides  belong  to  four  prin- 
cipal types:  erythema  (roseola);  the  papule;  the  ulceration;  excep- 
tionally, the  bulla  (in  congenital  syphilis). 

These  various  morphological  types  may  be  seen  in  juxtaposition, 
constituting  polymorphous  eruptions. 

In  a  general  way,  however,  one  type  almost  invariably  predomi- 
nates; I  have  described  these  eruptive  forms  in  the  first  part  of  this 
book,  to  which  the  reader  is  referred;  here  it  will  suffice  to  retouch 
the  picture. 

1.  The  erythematous  syphilides  are  simple  roseola,  which  is  almost 
regularly  the  first  eruption;  and  circinate  roseola,  delayed,  recurrent 
and  rebellious  (p.  41). 

2.  The  papular  syphilides,  often  precocious,  include,  according  to 
the  size  of  the  lesions,  a  lenticular  or  common  form  (p.  142);  a 
miliary  form  which  is  follicular  and  obstinate  (p.  396);  a  nummular 
form  (p.  144);  and  numerous  morphological  varieties:  papulo- 
squamous or  psoriatiform  (p.  113);  papulo-crusted  (p.  172);  and 
vegetative  (p.  247).  To  the  papular  type  should  be  annexed,  in 
my  opinion,  the  palmar  and  plantar  keratodermic  syphilides  (p.  216), 
which  may  be  precocious  or  delayed,  but  invariably  rebellious. 


020  INFECTIOUS  DERMATOSES  DUE  TO  PROTOZOA 

3.  The  ulcerative  syphilides  are  especially  serious  and  constitute 
varieties  which  are  malignant  from  the  start  (p.  286). 

4.  The  bullous  -syphilides  are  peculiar  to  precocious  hereditary 
syphilis  (p.  177). 

This  enumeration  does  not  exhaust  the  list  of  cutaneous  mani- 
festations of  the  secondary  stage;  there  still  remain  to  be  mentioned: 

.">.  Pigmentary  disturbances  (p.  320). 

6.  Lesions  of  the  adnexa,  the  hairs  (p.  411)  and  nails  (p.  436). 

It  is  important  to  note  that  these  various  types  of  lesions  are 
characteristic  only  on  the  skin.  On  the  mucous  membranes  and 
even  on  the  epidermis  in  macerated  regions,  these  types  lose  their 
distinctiveness  and  tend  toward  a  more  or  less  erosive  and  oozing, 
hence  highly  contagious  common  form,  which  is  currently  desig- 
nated under  the  name  of  mucous  patch. 

Secondary  Syphilides  of  the  Mucosa  or  Mucous  Patches. — This  is 
the  most  common  among  secondary  lesions  and  it  may  be  stated 
that  few  syphilitics  are  exempt  from  it.  Through  their  contagious- 
ness, mucous  patches  acquire  social  importance,  for  they  are  respon- 
sible for  most  transmissions. 

They  usually  appear  after  the  first  eruptive  manifestation; 
they  often  recur  repeatedly  during  the  first  two  or  three  years; 
especially  when  provoked  by  local  irritations — tobacco  and  a  bad 
condition  of  the  teeth  for  buccal  or  pharyngeal  patches;  uncleanli- 
ness  for  genital  and  anal  patches.  They  have  been  noted  in  the 
sixth  and  eighth  year  and  are  held  responsible  for  the  very  rare 
and  extremely  doubtful  cases  of  syphilitic  infection  in  the  twelfth 
and  even  in  the  eighteenth  year. 

Mucous  patches  may  be  situated  at  any  point  of  the  mouth,  the 
lips,  the  isthmus  and  the  pharynx,  especially  on  the  tonsils  and 
faucial  pillars,  the  commissure  of  the  lips  and  in  the  vicinity  of 
carious  teeth;  at  any  point  of  the  vulva;  on  the  prepuce  and  glans, 
around  the  anus,  on  the  conjunctiva?,  in  the  nasal  fossse,  in  the 
larynx;  sometimes  even  in  the  axilla?,  at  the  umbilicus,  or  more 
frequently  between  the  toes.  The  syphilides  designated  as  mucous 
patches  of  the  skin  have  been  previously  mentioned  (p.  144). 

A  distinction  is  made  between  several  varieties  of  syphilides  of 
the  mucous  membranes,  which  correspond  to  the  cutaneous  syphil- 
ides, representing  a  possible  localization  of  the  latter. 

Erythematous  syphilides,  simple  red  spots,  are  seen  especially  on 
the  palate,  on  the  cheeks  and  on  the  labia  minora. 

Opaline  plaques,  ordinary  mucous  patches,  the  most  widely  dis- 
tributed variety,  are  characterized  by  a  slight,  sometimes  hardly 
papular  elevation,  on  which  the  epidermis  is  swollen  and  whitish, 
not  eroded  nor  proliferating.  They  are  encountered  everywhere, 
notably  on  the  velum  of  the  palate  or  at  the  vulva;  they  may 
assume  a  fairly  characteristic  circinate  arrangement,  in  arcades. 


SYPHILIS  621 

The  pharyngeal  and  buccal  mucous  patches  are  sometimes 
diphtheroid,  to  such  a  degree  that  a  confusion  with  diphtheria 
occurred  in  cases  reported  by  Fournier.  It  is  probable  that  this 
appearance  is  the  result  of  a  superadded  infection  (fuso-spirillary 
association,  etc.). 

Erosive  or  papulo-erosive  syphilides  are  papular  syphilides  whose 
squamous  epithelium  has  become  detached;  they  present  the  appear- 
ance of  distinctly  rounded  red  erosions;  they  often  become,  or  have 
been  opaline.  The  papular  mucous  patches  are  known  outside  of 
France  as  flat  condylomata  [condyloma  latum]. 

Papulo-hypertrophic  and  proliferative  mucous  patches  develop 
especially  in  uncleanly  persons,  at  the  vulva  or  in  its  vicinity,  in 
the  genitocrural  and  intergluteal  folds  and  sometimes  at  the  buccal 
commissures;  on  the  tongue,  notably  on  its  posterior  third,  they 
may  constitute  what  the  French  call  "toad's  back  tongue."  I  have 
seen  enormous  patches  of  this  kind  on  a  wholly  neglected  scalp. 
They  consist  of  elevations  the  size  of  a  pea  to  that  of  the  thumb  or 
larger,  sometimes  nearly  a  centimeter  thick,  with  a  granular  or 
papillomatous  surface,  discharging  a  turbid  and  yellowish  serous 
fluid  with  a  fetid  odor. 

Ulcerative  syphilides  of  the  mucous  membranes  are  less  common, 
they  are  observed  on  the  lips,  at  the  commissures,  the  gums,  the 
pharynx  and  on  all  parts  of  the  vulva. 

Certain  syphilitic  lesions  of  the  tongue  known  as  smooth  patches 
or  "mowed-lawn"  patches  are  usually  regarded  as  related  to  mucous 
patches.  These  are  dry,  red,  non-eroded  patches  deprived  of  their 
papilla?,  usually  of  an  oval  shape;  they  may  become  papular.  Their 
onset  is  often  delayed  and  may  even  occur  in  the  course  of  the 
tertiary  stage;  Fournier  considered  them  as  contagious.  They 
are  very  slightly  amenable  to  mercurial  treatment  and  last  several 
weeks  or  even  months. 

Although  usually  painless,  mucous  patches  may  interfere  with 
movements,  causing  dysphagia,  etc. 

The  diagnosis  of  mucous  syphilides  is  easy  when  they  occur  in 
the  course  of  a  long  train  of  symptoms;  inversely,  it  frequently 
happens  in  practice  that  they  furnish  valuable  information  in 
doubtful  cases;  but  it  would  be  venturesome  to  base  a  diagnosis 
of  syphilis  exclusively  upon  the  presence  of  mucous  patches,  even 
when  they  assume  an  appearance  which  may  seem  to  be  typical. 

The  principal  causes  of  error  are  as  follows,  in  the  mouth :  aphthae 
are  entirely  round,  yellowish  with  a  narrow  carmine  margin  and  very 
painful.  Herpes  appears  suddenly,  is  painful  and  polycyclic.  The 
bullous  dermatoses,  hydroa,  may  produce  lesions  almost  identical  with 
mucous  patches.  Perleche  is  an  opaline  erosion  situated  exclusively 
at  the  commissures  of  the  lips,  but  encroaching  upon  the  cutaneous 


622         INFECTIOUS  DERMATOSES  DUE  TO  PROTOZOA 

epidermis  of  the  vicinity;  it  is  epidemic  in  schools  and  due  to  a 
streptococcus.  Glossitis  areata  exfoliativa  is  characterized  by  its 
special  border.  Leukoplakia,  buccal  lichen  planus  and  median 
rhomboidal  glossitis,  etc.,  are  dry,  stationary  or  very  persistent 
lesions.  Mercurial  stomatitis  is  a  diffuse  inflammation,  sometimes 
with  peridental  or  lingual  ulcerations  closely  resembling  mucous 
patches;  a  coincidence  is  possible. 

Sources  of  error  in  the  genital  region  are  represented  by:  trau- 
matic lesions,  which  are  irregular  and  ephemeral;  erosive  balano- 
posthitis,  which  is  characterized  by  whitish  circinate  forms  which 
may  be  removed  by  friction. 

Soft  chancre  is  purely  ulcerative  and  suppurates  profusely;  it  is 
auto-inoculable.  Proliferative  herpes  of  the  vulva,  a  very  rare 
disease,  closely  simulates  the  papulo-erosive  syphilides.  The  same 
is  true  for  the  post-erosive  papular  erythema  of  nursing  infants 
(Fig.  1).  Finally,  in  uncleanly  individuals,  one  may  see  in  the 
vicinity  of  the  anus  absolutely  syphiloid  patches  of  proliferative 
dermatitis,  which  are  of  commonplace  character  (A.  Fournier  and 
Brouardel). 

[The  demonstration  of  spirochete  pallida  on  the  surface  of  a 
lesion  of  the  mucosa  is  not  always  easy.  When  it  can  be  made 
with  certainty  the  diagnosis  is  placed  beyond  a  doubt.] 

Tertiary  Stage. — While  it  is  possible  to  enumerate  in  a  few  lines 
the  principal  secondary  syphilitic  lesions  and  to  give  an  idea  of  the 
course  of  this  stage,  such  a  sketch  is  altogether  impracticable  in 
regard  to  tertiary  syphilis;  its  domain  is  too  extensive,  its  course  too 
varied  and  too  irregular.  I  shall  accordingly  discuss  only  its  cuta- 
neous and  mucous  lesions. 

Tertiary  Syphilides.- — The  general  features  distinguishing  these 
from  the  secondary  symptoms  are  as  follows:  They  are  deep  and 
serious,  not  superficial  and  benign  lesions,  of  an  ulcerative  or  sclerotic 
type,  not  undergoing  absorption;  limited  and  regional,  not  profuse 
and  scattered;  monomorphous,  often  with  a  well-marked  tendency 
to  become  arranged  in  groups  and  to  assume  a  circinate  configur- 
ation, "to  become  disciplined"  to  use  an  expression  of  Fournier's. 

The  circinate  or  rather  semicircular  arrangement  of  an  eruption 
would  be  incorrectly  interpreted  as  characteristic  of  syphilitic 
lesions;  in  the  first  place,  its  constituent  eruptive  lesions  must  be 
taken  into  consideration.  The  following  general  statements  can  be 
made:  While  rare  in  secondary  syphilis  (syphilides  in  arcades, 
mucous  patches  in  arcades),  a  circinate  arrangement  is  very  common 
in  the  tertiary  syphilides.  It  is  encountered  furthermore  in  some 
cases  of  lupus,  in  some  eczemas  and  psoriasis,  in  many  erythemas, 
in  recurrent  pemphigus,  sometimes  in  mycosis  fungoides,  in  lichen 
planus,  lichen  scrofulosorum,  parapsoriasis  en  plaques,  etc.     The 


SYPHILIS  623 

eczematides  and  more  particularly  the  cutaneous  trichophytosis, 
rather  form  complete  circles. 

The  question  of  the  contagiousness  of  these  tertiary  lesions 
had  been  settled  in  the  negative  sense  or  very  nearly  so.  Modern 
methods  of  investigation,  however,  notably  inoculation  into  mon- 
keys, have  shown  that  a  certain  number  of  these  lesions  are  virulent, 
the  proportion  being  difficult  to  indicate.  We  do  not  know  if  the 
spirochete,  as  has  been  supposed,  exists  here  in  a  different  form 
from  that  which  it  assumes  in  chancre  and  in  the  secondary  mani- 
festations [but  there  is  no  necessity  for  this  assumption;  a  gumma  is 
the  effect  of  a  spirochete  in  loco  acting  on  a  soil  modified  by  the 
existing  disease.  Spirochetes  have  been  found  in  gummas  though 
in  very  small  numbers.  I  am  of  the  opinion  that  encysted  or  rest- 
ing forms  must  also  exist;  but  this  lacks  proof.] 

The  morphological  aspects  under  which  the  tertiary  syphilides 
may  manifest  themselves  have  been  previously  described;  they  are 
classified  under  six  headings,  as  follows : 

1.  Tertiary  erythemas  (p.  41). 

2.  Tubercular  syphilides,  circinate  or  in  patches  (p.  253). 

3.  Ulcerative  syphilides,  of  several  varieties  (p.  285);  tuberculo- 
ulcerative,  atypical  gummous,  sclerogummous  and  phagedenic. 

4.  Syphilitic  gummas  (p.  267). 

5.  Tertiary  vegetative  syphilides  (p.  247). 

6.  Diffuse  hypertrophic  syphilomas  and  syphilitic  elephantiasis  (p. 
368). 

These  various  lesions  may  occupy  any  region  of  the  integument 
or  of  the  mucous  membranes.  It  may  serve  as  a  useful  guide, 
however,  to  mention  the  types  which  occur  especially  in  some  special 
regions. 

The  center  of  the  face,  the  nose  and  the  lips,  is  one  of  the  elective 
foci  of  tertiary  syphilis  in  all  its  forms,  dry  tubercular,  ulcerative, 
proliferating  and  leontiastic.  Superficial  confluent  tubercular  syph- 
ilides, closely  analogous  to  rosacea,  are  also  observed  in  this  location. 

In  the  mouth,  on  the  palate  and  the  pharynx,  superficial  tuber- 
cular and  ulcerat  ve  syphilides  are  met  with,  as  well  as  perforating 
gumma. 

On  the  tongue,  there  occur  gummas,  gummous  and  sclero- 
gummous infiltrations,  sclerotic  glossitis  and  sometimes  tubercles. 

On  the  scalp,  gummas  and  tuberculo-ulcerative  syphilides  are 
not  uncommon;  the  crusted  and  superficial  variety  of  the  latter 
may  simulate  psoriatiform  eczematides.  To  the  palmar  and  plantar 
regions  belong  the  psoriatiform  so-called  keratodermic  syphilides. 
On  the  extremities,  syphilitic  elephantiasis  may  develop.  On  the 
external  genital  organs  of  both  sexes,  gummous  infiltrations  and 
gummas  are  found,  as  well  as  proliferative,  chancriform,  phage- 
denic syphilides,  etc. 


624  INFECTIOUS  DERMATOSES  DUE  TO  PROTOZOA 

For  the  diagnosis  of  each  of  these  forms,  the  reader  is  referred  to 
the  description  of  the  eruptive  lesion  which  distinguishes  it  (Part  I, 
Morphology). 

Congenital  Syphilis.  The  teachings  on  the  subject  of  congenital 
syphilis  and  the  multiple  problems  involved  in  its  investigation 
have  been  greatly  influenced  by  recent  scientific  acquisitions,  the 
discovery  of  the  spirochete  and  the  introduction  of  the  Wassermann 
test.  Without  entering  into  details,  I  shall  limit  myself  to  stating 
the  conclusions  which  are  agreed  upon  or  at  least  tend  to  become 
generally  accepted. 

Hereditary  syphilis,  better  named  congenital,  is  always  of  maternal 
origin;  it  is  transmitted  from  the  mother  to  the  fetus  by  way  of  the 
placenta  rather  than  through  the  germ-plasm  or  the  ovum. 

As  the  mother  of  a  child  born  with  syphilis  is  always  herself 
syphilitic,  even  if  she  appears  healthy  (Wassermann  reaction),  this 
fact  affords  a  simple  explanation  of  Colles'  law  (immunity  of  the 
mother  of  a  child  born  with  syphilis)  and  Prof  eta's  law  (immunity 
of  an  apparently  healthy  child  toward  its  syphilitic  mother).  So- 
called  conceptional  syphilis,  or  through  reflex  ("choc  en  retour") 
in  utero  (syphilization  of  the  mother  by  a  fetus  conceived  from  a 
syphilitic  father)  is  an  error  in  interpretation  of  the  facts.  A 
syphilitic  father  can  transmit  virulent  syphilis  to  his  child  only 
through  intermediate  infection  of  the  mother;  but  on  the  other 
hand,  without  syphilizing  the  mother  he  can  transmit  to  his  off- 
spring, like  an  alcoholic  or  tuberculous  father,  both  physical  and 
psychic  disturbances  of  development  and  a  tendency  to  malfor- 
mations; this  heredo-dystrophy  mayor  may  not  be  associated  with 
congenital  syphilis  of  the  child. 

Congenital  syphilis  differs  from  acquired  syphilis  in  a  funda- 
mental factor:  the  infection,  of  placental  origin,  takes  place  by  the 
hematogenous  route  and  is  visceral  from  the  start.  The  primary 
stage  is  accordingly  absent  in  hereditary  syphilis;  there  is  no 
chancre;  moreover,  the  secondary  symptoms  and  the  visceral 
manifestations  of  tertiary  character  are  intermingled  instead  of 
successive.    The  course  is  therefore  much  less  regular. 

In  addition,  the  specific  manifestations  may  become  associated 
with  dystrophic  disturbances,  malformations  and  various  patho- 
logical tendencies,  due  to  poisoning  of  the  germinal  tissue,  sperma- 
tozoa and  ova,  as  well  as  infection  of  the  entire  maternal  organism, 
so  that  it  is  readily  understood  that  the  clinical  picture  of  congenital 
syphilis  may  be  rather  polymorphous. 

[The  offspring  of  a  woman  in  the  early  stages  of  syphilis  is  always 
syphilitic;  in  the  later  stages  the  child  may  or  may  not  be  syphilitic. 
In  a  series  of  pregnancies  the  first  products  of  gestation  may  be 
abortions  or  dead  children,  then  children  born  alive  and  syphilitic, 


SYPHILIS  625 

then  a  series  of  apparently  healthy  children.  Some  of  these  appar- 
ently healthy  children  will  really  be  free  from  syphilis  and  some 
may  develop  signs  of  syphilis  within  a  few  years;  or  possibly  the 
first  lesion  will  appear  only  after  the  lapse  of  many  years.  Some- 
times among  the  later  children  of  a  series,  healthy  and  syphilitic 
children  alternate. 

The  explanation  of  these  phenomena  is  simple  but  not  generally 
understood.  The  blood  of  the  syphilitic  mother  in  the  first  year  or 
two  after  infection  is  loaded  with  spirochetes  some  of  which  are 
sure  to  enter  the  uterine  arteries  and  infect  the  fetus,  producing 
there  the  active  lesions  of  syphilis.  In  the  tertiary  stage  of  the 
mother's  syphilis  the  spirochetes  have  become  fixed  in  her  tissues 
and  her  blood-stream  only  occasionally  contains  a  few  spirochetes. 
Under  these  conditions  it  is  a  matter  of  chance  whether  or  not  the 
spirochetes  will  reach  the  placenta  and  thus  infect  the  fetus.  But 
the  blood  of  the  fetus  shares  the  quality  of  its  mother's  blood;  in 
late  syphilis,  the  fetal  blood  is  ab  ovo  the  blood  of  a  tertiary  syph- 
ilitic and  contains  the  same  substances  which  have  given  to  the 
mother  that  kind  of  immunity  which  Neisser  called  anergy.  It  is 
this  condition  which  renders  her  immune  to  a  fresh  infection  though 
it  offers  no  protection  against  local  tertiary  lesions.  The  spirochetes 
of  a  tertiary  syphilitic  mother  that  happen  to  penetrate  to  the  fetus 
find  conditions  there  like  those  in  the  mother.  They  produce  no 
acute  syphilis  but  becoming  localized  in  the  tissues  develop  the  late 
lesions  of  syphilis  hereditaria  tarda.] 

The  cutaneous  and  mucous  manifestations  alone  are  to  be  con- 
sidered in  this  book;  the  other  symptoms  will  accordingly  receive 
merely  a  brief  mention. 

A  classical  distinction  is  made  between  early  and  delayed  mani- 
festations of  congenital  syphilis. 

Precocious  congenital  syphilis  sometimes  manifests  itself  at  birth 
by  a  peculiar  fades:  the  skin  is  lifeless,  wrinkled,  flaccid,  withered, 
like  that  of  a  very  old  man;  the  skull  is  deformed,  with  an  abnor- 
mally high  forehead  ("olympian  brow"),  a  natiform  cranium, 
hydrocephalus,  dilatation  of  the  cranial  veins  and  general  athrepsia 
(Fig.  182). 

At  birth,  children  with  congenital  syphilis  may  present  three 
symptoms:  syphilitic  pemphigus;  very  frequently,  an  irritative 
serous,  later  purulent,  coryza,  drying  in  greenish  crusts  and  inter- 
fering with  respiration  and  nursing;  mucous  patches,  situated  espe- 
cially on  the  lips,  often  at  the  commissures,  either  fissured  or 
radiating,  rose-colored  or  opaline,  oozing,  crusted,  sometimes  with 
an  indurated  base  and  painful;  they  are  a  common  cause  of  infec- 
tion of  wet-nurses. 

Very  soon,  in  the  first  weeks  of  life  and  usually  before  the  fourth 
40 


626        1SFECTI0US  DERMATOSES  due  to  protozoa 

month,  the  cutaneous  syphilides  make  their  appearance.  These 
have  been  especially  well  studied  by  Jacquet. 

Polymorphous  erythemato-papular  syphilides  consist  of  more  or 
less  rounded  salmon-colored  or  dark-red  erythematous  spots,  situated 
on  the  buttocks,  on  the  lower  limbs,  on  the  neck,  around  the  mouth 
or  in  the  folds.  Some  fade  and  disappear  while  others  increase  in 
size  and  become  scaly,  or  thicken  into  papular  discs;  the  elevation 
is  often  marked  at  the  borders  (cirdnate  erythemato-papular  syphilide  I 
and  sometimes  at  the  center  of  the  spots  (extended  papulo-lenticular 
syphilide).  A  well-marked  "collarette  of  Biett"  (p.  142)  may  be 
observed  at  their  circumference. 

Jacqnet  has  pointed  out  that  the  palmar  and  plantar  syphilides, 
known  as  syphilitic  pemphigus,  are  of  the  same  type  and  become 
bullous  only  in  consequence  of  local  factors. 


Fig.  182.— Early  congenital  syphilis;  child  of  three  months.  Note  the  hydro- 
cephalus, the  dilatation  of  the  cranial  veins,  the  papulo-erosive  syphilides  of  the 
buttocks,  loins,  thighs,  etc., the  large  abdomen  and  the  puny  limbs. 

The  erythemato-papular  syphilides  may  become  erosive  through 
maceration,  or  crusted  and  impetiginous,  or  sometimes  ulcerative 
at  points  exposed  to  pressure  or  irritated  by  fecal  matter;  or,  rarely, 
very  scaly  and  psoriatiform.  Furthermore,  an  acneiform  syphilide 
has  been  described,  formed  by  small  umbilicated  papules,  centered 
by  a  small  crust  and  agglomerated  in  patches. 

These  polymorphous  erythemato-papular  syphilides  are  often  very 
difficult  to  distinguish  from  the  gluteal  erythema  of  the  newborn 
(p.  31).  They  are  the  substitute  in  congenital  syphilis  of  the 
roseola  and  the  various  papular  syphilides  of  adults;  as  a  rule  they 
are  associated  with  mucous  patches  and  sometimes  with  lesions  of 
the  nails  and  alopecia.     Gummas  are  rare. 

Proper  treatment  of  newborn  infants  having  congenital  syphilis 
saves  the  lives  of  the  majority  [without  proper  treatment  very 
few  of  them  survive  even  a  year].  These  children  must  never  be 
entrusted  to  a  healthy  wet-nurse,  but  must  be  nursed  by  their  own 
mother.     In  order  to  protect  their  digestive  functions,  mercurial 


SYPHILIS 


627 


medication  by  the  mouth  with  van  Swieten's  fluid,  etc.,  is  prefer- 
ably replaced  by  mercurial  inunctions  (1  or  2  grams  of  mercurial 
ointment  daily).  It  is  advantageous  to  administer  injections  of 
novarsenobenzol  in  watery  solution  (5  mg.  as  the  maximum  dose 
per  kilogram  of  body  weight  per  week)  into  a  scalp  vein  or  in  oily 
suspension  into  the  buttock. 


Fig.  183. — Congenital  syphilis.  Circinate  tuberculo-squamous  syphilide  on  the  thigh 
of  a  girl  aged  eleven  years. 


Syphilis  congenita  tarda  is  the  form  observed  in  older  children, 
in  adults  or  even  in  old  persons.  For  this  chapter  of  pathology  we 
are  almost  entirely  indebted  to  the  contributions  of  my  teacher, 
A.  Fournier,  prior  to  whom  the  remote  evidences  of  congenital 
syphilis  were  generally  referred  to  scrofulo-tuberculosis,  rickets,  etc. 
It  has  been  claimed  that  these  patients  must  have  had  early  mani- 
festations and  that  it  is  only  the  diagnosis  that  is  delayed  in  such 
cases.  This  is  probable  but  not  certain.  The  didactic  and  practical 
importance  of  the  subject  is  nevertheless  considerable. 

The  remote  symptoms  of  congenital  syphilis  are  in  part  specific 
and  in  part  dystrophic  in  character. 


628 


ISEECTIOVS    DERMATOSES   DUE    TO   I'h'OTOZOA 


Decidedly  specific  are  those  which  plainly  present  the  features  of 
tertiarism  (Fig.  183);  these  require  therefore  no  special  description. 
Aside  from  the  external  integument,  they  affect  chiefly  the  velum 
of  the  palate,  the  pharynx,  the  tongue,  the  nasal  fossa?  and  the 
genital  organs  and  are  as  a  rule  essentially  ulcerative  and  destructive. 

Under  the  name  of  stigmata  of  congenital  syphilis,  a  series  of 
malformations,  developmental  disturbances  and  lesions  have  been 
grouped,  whose  characters  point  to  syphilis  in  the  parents  on  simple 
examination  of  the  patient.  Some  are  of  a  dystrophic  character, 
while  others  are  residues  of  specific  lesions;  efforts  are  now  under 
wax   to  separate  these  two  groups  of  symptoms. 

The  principal  signs  are  the  following:  Hutchinson's  triad,  namely 
dental  malformations  (Fig.  184),  ocular  lesions  and  auditory  dis- 
turbances; bony  deformities  such  as  cranial  and  nasal  malforma- 
tions, "sabre-blade"  tibia  and  exostoses;  testicular  atrophy;  infan- 
tilism; gluteal  cicatrices  of  Parrot  and  radiating  cicatrices  of  the 
lips. 


Fig.   184. — Congenital  syphilis.    Hutchinson's  teeth 


Pathological  Anatomy. — Before  the  discovery  of  the  spirochete, 
the  syphilitic  lesions  had  already  been  recognized  as  possessing  the 
features  of  an  infectious  inflammation;  this  affects  in  the  first  place 
the  arterial  and  venous  bloodvessels,  altering  the  vascular  walls  and 
giving  rise  around  them  to  the  production  of  cellular  infiltrations 
composed  for  the  most  part  of  plasmocytes. 

The  more  or  less  circumscribed  or  diffuse  newformations  which 
make  up  these  infiltrations  are  capable  of  resolution  in  the  primary 
or  secondary  stage  of  the  disease,  in  the  sense  that  they  may  undergo 
retrogression  and  practically  complete  absorption;  the  tertiary 
new  formations,  on  the  contrary,  are  incapable  of  resolution  and 
tend  lo  form  sclerotic  tissue,  provided  they  do  not  undergo  necro- 
biosis; this  may  occur  early,  while  the  pathological  tissue  still  has 
an  embryonic  structure,  or  later,  after  the  sclerosis  has  become 
established.  'The  name  of  giumnous  degeneration  is  employed  to 
designate  this  necrotic  process  in  either  case. 


SYPHILIS  629 

In  .syphilitic  chancre,  the  cellular  infiltration  of  the  cutis  is  very 
dense;  the  connective-tissue  bundles  are  swollen,  the  walls  of  the 
bloodvessels  are  greatly  inflamed,  the  epidermis  is  thickened  at  the 
borders,  but  has  lost  a  number  of  its  layers  at  the  center,  the  remain- 
der being  infiltrated  with  leukocytes  and  fibrine  as  well  as  degener- 
ated; in  many  cases,  thinned  and  elongated  interpapillary  buds 
are  its  only  residue.  The  treponema  flourishes,  especially  in  the 
vascular  walls,  whence  they  seem  to  emigrate  in  part  into  the 
vascular  lumen,  which  is  very  important  in  view  of  the  generali- 
zation of  the  infection;  in  part,  into  the  connective-tissue  bundles 
and  spaces,  whence  the  lymphatics  carry  them  into  the  glands; 
and  finally  in  the  epidermis,  where  they  may  be  transmitted  by 
contagion. 

The  lenticular  papule  may  serve  as  the  model  of  a  secondary 
syphiloma  (Fig.  31).  The  infiltration  of  plasma  cells  interspersed 
with  a  few  giant  cells  is  arranged  in  more  or  less  continuous 
perivascular  cuffs.  The  epidermis  is  merely  stretched;  or  it  may 
be  parakeratotic,  or  edematous  and  infiltrated  with  leukocytes,  or 
degenerated,  resulting  in  the  formation  of  scales,  crusts,  erosions  or 
ulcerations. 

In  the  roseola  the  cellular  infiltration  is  very  slight.  It  is  some- 
what more  considerable  in  the  mucous  patches,  which  may  have  the 
structure  of  papules,  with  an  opaline  epithelium  through  separation 
of  the  cells  and  very  abundant  immigration  of  white  corpuscles. 
These  lesions  are  literally  teeming  with  spirochetes. 

The  tertiary  lesions  differ  from  the  preceding  in  their  course 
rather  than  in  their  characters;  the  treponema,  however,  has  only 
very  rarely  been  demonstrated. 

Genuine  syphilitic  gumma  seems  to  originate  through  thrombo- 
phlebitis in  the  vascular  plexus  of  the  hypoderm;  the  profuse 
cellular  newformation  of  which  it  consists  undergoes  liquefaction 
while  at  the  same  time  the  stroma  becomes  necrotic. 

In  syphilitic  tubercle,  the  newformation,  in  which  the  bloodvessels 
and  lymphatics  are  greatly  dilated,  is  partitioned  by  sclerotic  strands. 
As  compared  with  the  papule,  it  is  therefore  more  fibrous,  hence  its 
hardness;  contains  more  venous  blood,  hence  its  dark  color;  and 
the  sclerosis  persists  after  its  disappearance,  hence  the  cicatrix 
which  it  leaves  behind  (Fig.  87).  The  epidermis  may  be  hyper- 
trophied  in  the  proliferative  varieties;  or  it  may  be  edematous, 
degenerated  and  infiltrated  with  leukocytes  in  the  tuberculo-crusted 
and  tuberculo-ulcerative  forms.  The  crust,  which  characterizes 
the  last  two  forms  as  well  as  the  secondary  ulcerative  sjphilides  of  the 
precocious  malignant  form,  develops  at  the  expense  of  the  epidermis 
and  the  infiltrated  necrotic  upper  layer  of  the  cutis;  it  accordingly 
precedes  the  ulceration.     Endarteritis  and  phlebitis  are  regularly 


030         INFECTIOUS  DERMATOSES  DUE  TO  PROTOZOA 

found  around  all  tertiary  syphilomas.  All  these  forms  may  present 
a  tuberculoid  structure  (Nicolas  and  Favre). 

The  lesions  of  congenital  syphilis  do  not  markedly  differ  from 
those  of  acquired  syphilis.  The  abundance  of  spirochetes  in  its  early 
manifestations  has  already  been  referred  to. 

Diagnosis. — The  diagnosis  of  syphilis  should  always  be  guarded; 
I  repeat  that  the  patient  should  be  very  cautiously  informed  of  its 
existence. 

Sometimes  the  diagnosis  is  obvious  from  the  start,  while  in  other 
cases,  numerous  and  painstaking  investigations  are  required.  It 
may  happen  that  in  spite  of  these  investigations  no  definite  con- 
clusion is  possible.  Even  in  countries  supplied  with  well-informed 
physicians,  a  considerable  number  of  previously  undiscovered  cases 
of  syphilis  are  met  with  and  this  number  has  grown  since  our 
knowledge  of  the  specific  origin  of  the  so-called  parasyphilitic 
diseases  and  since  the  common  employment  of  the  Wassermann 
reaction. 

In  connection  with  every  type  of  syphilitic  symptoms,  I  have 
indicated  its  diagnostic  features,  based  on  its  objective  character- 
istics. Some  of  these  are  indicative,  notably  the  typical  hard 
chancre,  roseola,  lenticular  papular  eruption,  arciform  syphilides, 
alopecia  areolata,  pigmentary  syphilide  of  the  neck,  circinate 
tertiary  syphilides,  etc. 

When  it  is  not  possible  to  affirm  the  existence  of  syphilis  from 
the  morphological  aspect  of  a  given  lesion,  as  is  true  in  by  far  the 
majority  of  cases,  there  is  a  series  of  indirect  measures  at  our  com- 
mand that  enable  us  to  arrive  at  a  certainty;  these  are  of  unequal 
intrinsic  value  and  not  indiscriminately  applicable  in  all  stages  of  the 
disease;  nor  is  it  always  possible  or  necessary  to  employ  them  all. 

Among  these  procedures,  some  are  of  a  clinical  nature  and  furnish 
only  more  or  less  probable  data. 

They  are  based  upon:  (1)  the  presence  of  concomitant  lesions; 
certain  associations  are  almost  pathognomonic;  I  have  emphasized 
the  value  of  progressive  general  glandular  enlargement;  (2)  the 
regular  succession  and  sequence  of  the  lesions;  and  (3)  on  the 
history  of  exposure  to  contagion  and  the  examination  of  the  con- 
taminating party  (Bassereau).  The  ex-juvantibus  method  [test  by 
treatment]  has  too  many  serious  disadvantages  to  justify  its 
employment. 

Recent  discoveries  have  enriched  these  traditional  diagnostic 
principles  by  the  introduction  of  new  scientific  procedures  belonging 
to  the  domain  of  the  laboratory. 

The  demonstration  of  the  spirochete,  in  stained  smears  or  by 
direct  ultra-microscopical  examination  of  the  serous  discharge, 
constitutes  the  method  of  choice  in  case  of  oozing  lesions  of  the 


SYPHILIS  631 

first  stages,  namely  a  chancre  or  mucous  patches;  a  positive  result 
is  absolute  proof.  However,  this  demonstration  fails  in  the  ulcer- 
ative lesions,  even  of  the  secondary  period;  it  is  very  complicated 
in  non-ulcerative  syphilides  and  negative  tests,  even  when  repeated, 
possess  no  value.  In  the  case  of  tertiary  syphilides,  this  method  is 
of  no  assistance  at  all. 

The  demonstration  of  the  spirochetes  in  biopsy-sections  requires 
more  time  and  a  more  elaborate  technic;  its  value  is  open  to  the 
same  objections  as  those  of  the  direct  procedure.  It  is  applicable  to 
the  non-ulcerative  lesions  of  the  most  virulent  stage  of  the  disease. 

The  method  of  demonstrating  the  virulence  of  a  lesion  by  inocula- 
tion into  monkeys,  as  formulated  by  Thibierge  and  Ravaut,  or  by 
inoculation  of  the  rabbit's  cornea  or  scrotum,  is  absolutely  con- 
clusive when  the  outcome  is  positive.  But  its  inherent  difficulties 
and  the  delay  prevent  its  employment  as  a  customary  procedure. 

The  sero-diagnostic  method  of  Wassermann-Bruck-Neisser,  based 
on  the  complement-fixation  method  of  Bordet-Gengou,  depends, 
not  upon  the  demonstration  of  the  noxious  agent,  but  upon  the 
demonstration  of  the  resulting  humoral  changes.  Its  technic  is 
extremely  delicate;  it  necessitates  minute  precautions  with  con- 
trols and  a  correct  interpretation  of  the  findings. 

The  fact  is  now  known  that  the  Wassermann  reaction  is  not 
strictly  specific,  for  a  positive  reaction  is  yielded  by  yaws,  trypanoso- 
miases and  leprosy.  In  a  general  way,  however,  under  ordinary 
conditions  and  with  a  reliable  worker,  a  positive  outcome  may  be 
credited  with  absolute  value  and  a  series  of  negative  results  with  a 
value  of  great  probability. 

Sero-diagnosis  is  not  applicable  in  the  initial  stage  of  the  chancre, 
because  the  reaction  does  not  appear  until  about  three  weeks  after 
the  onset  of  the  primary  lesion.  It  is  a  valuable  aid  in  the  secondary 
stage  and  especially  in  the  tertiary  stage.  It  is  well  to  keep  in 
mind,  however,  that  the  only  information  supplied  is  to  the  effect 
that  the  individual  is  syphilitic,  without  justifying  a  statement  that 
a  given  doubtful  lesion  presented  by  this  individual  is  itself  of 
syphilitic  nature.  The  Wassermann  reaction  is  most  serviceable 
in  the  latent  stages  of  the  disease,  the  other  methods,  except  the 
luetin  test  which  will  be  discussed  presently,  being  inapplicable  at 
these  times.  It  may  also  be  utilized  to  a  certain  extent  in  the 
direction  of  the  treatment. 

Milian  and  others  have  studied  under  the  name  of  reactivation 
the  reappearance  of  a  positive  Wassermann  reaction  under  the 
influence  of  treatment  with  arsenicals;  it  is  claimed  to  occur  early 
(from  the  fifth  to  eleventh  day)  in  the  secondary  stage,  but  is  transi- 
tory; rather  delayed  (toward  the  fifteenth  day)  and  generally 
prolonged  in  the  tertiary  stage.     [In  my  opinion  the  "provocative" 


632  INFECTIOUS  DERMATOSES  DUE   TO  PROTOZOA 

Wassermann  test  is  not  only  useless  but  is  apt  to  be  misleading. 
Cf.  Am.  Journ.  Syphilis,  April,  1919.] 

For  the  cutaneous  reaction  to  luetin,  credit  is  due  to  Noguchi 
(1912).  Luetin  is  a  sterilized  emulsion  of  a  culture  of  six  strains  of 
Spirochete  pallida;  it  is  employed  in  intradermic  injections.  The 
results  yielded  by  it  are  not  always  very  reliable.  A  positive 
reaction  manifests  itself  after  twenty-four  to  forty-eight  hours,  by 
the  appearance  of  a  papular  or  pustular  elevation  which  lasts  a  week 
or  longer;  sometimes  it  is  sluggish  or  delayed. 

A  negative  reaction  is  erythematous  or  faintly  papular  and  sub- 
sides by  the  fifth  day.  It  is  claimed  that  the  percentage  of  positive 
results  is  only  33  in  the  primary  stage  and  47  in  the  secondary  stage, 
but  from  80  to  90  in  tertiary  syphilis,  whether  latent  or  congenital; 
so  that  there  is  no  conformity  with  the  Wassermann  reaction.  A 
certain  number  of  non-syphilitic  persons  react  likewise.  An  analo- 
gous reaction  to  that  of  luetin,  which  is  on  the  whole  only  a  manifes- 
tation of  allergy  has  been  obtained  on  the  other  hand  with  extracts 
of  syphilitic  organs  and  even  with  other  substances.  The  value  of 
the  luetin-reaction  is  still  a  matter  of  controversy.  [That  the 
reaction  is  not  specific  is  shown  by  the  fact  that  it  may  occur  after 
an  injection  of  agar  (Stokes)  and  possibly  other  substances;  more- 
over a  reaction  is  regularly  obtained  in  non-syphilitics  who  have 
ingested  iodides  as  long  as  a  month  before.] 

The  histological  diagnosis  of  syphilis  through  examination  by 
biopsy  has  been  relegated  to  a  secondary  rank;  under  certain  con- 
ditions and  especially  in  combination  with  sero-diagnosis,  this 
method  may  prove  serviceable. 

It  will  be  readily  understood  that  the  various  procedures  outlined 
above  may  be  combined  in  several  ways  according  to  the  supposed 
stage  of  the  disease. 

Treatment.— Syphilis  is  one  of  the  diseases  against  which  we  are  in 
a  good  state  of  preparedness. 

Lacking  a  preventive  or  curative  serum,  which  remains  to  be  dis- 
covered, we  possess  mercury  which  often  does  wonders  when  it  is 
properly  employed  and  well  tolerated;  and  there  are  furthermore 
the  recently  introduced  arsenical  compounds,  which  are  still  more 
powerful;  a  few  medicinal  adjuvants  and  hygienic  prescriptions 
complete  our  therapeutic  armamentarium. 

Mercury. — It  is  not  known  if  mercury  acts  directly  as  a  parasiti- 
cide, or  through  the  intermediation  of  antibodies,  or  by  increasing 
the  defensive  reactions  of  the  organism,  etc.  A  fewr  days  of  treat- 
ment suffice  to  render  the  demonstration  of  spirochetes  in  the  syphi- 
litic lesions  impossible.  At  any  rate,  mercury  not  only  cures  the 
symptoms  but  also  prevents  relapses  and  tertiarism  and  even 
hereditary  transmission.     Like  main'  others,   I  have  been  able  to 


SYPHILIS  633 

note  that  the  vast  majority  of  syphilitics  who  were  treated  with 
mercury  alone  for  a  long  time  and  with  good  doses  remained  definitely 
free  and  acquired  a  permanently  negative  sero-reaction. 

The  mode  of  introduction  of  the  medicinal  agent  is  not  of  capital 
importance  in  itself,  the  essential  factor  being  the  amount  which  has 
really  been  absorbed.  The  reason  why  the  old  mercurial  fumi- 
gations have  been  abandoned  and  the  obstacle  to  the  adoption  of  the 
inhalation  method,  through  the  mercurial  flannels  of  Merget  or 
through  the  powder-  or  ointment-bags  of  Welander,  which  the 
patient  must  wear  on  his  person  night  and  day,  consist  in  the 
uncertainty  as  to  the  dosage  absorbed  under  these  methods  of 
administration. 

Mercurial  inunctions  are  open  to  the  same  criticism;  furthermore, 
they  are  dirty  and  suggestive.  They  enjoy  great  popular  favor, 
however,  especially  abroad;  for  children  of  tender  years,  they  con- 
stitute the  procedure  of  choice.  [A  30  per  cent,  calomel  ointment 
seems  to  be  not  less  efficient,  and  has  the  avantage  of  cleanliness.] 

The  full-strength  or  50  per  cent,  mercurial  ointment  is  employed 
for  these  inunctions,  in  daily  doses  of  6  or  7  grams  for  a  man,  5 
grams  for  a  woman,  1  or  2  grams  for  a  newborn  child.  The  inunc- 
tions must  be  applied  for  a  long  time,  during  ten  to  fifteen  minutes, 
until  there  is  apparent  penetration;  the  regions  should  be  carefully 
alternated,  rubbing  on  the  first  two  days  one  of  the  sides  of  the 
thorax,  on  the  following  days  the  internal  aspect  of  one  of  the  limbs, 
after  which  the  series  is  resumed,  avoiding  the  axillse,  the  groins 
and  the  scrotum,  which  are  too  much  exposed  to  hydrargyria.  The 
treated  part  is  covered  with  gauze  for  the  night;  on  the  following 
morning  it  is  carefully  cleansed  with  soap  and  dusted  with  powder. 
[Since  mercury  is  slowly  vaporized  at  the  body  temperature  a  part 
of  the  effect  of  inunctions  is  due  to  respiratory  absorption.  Inunc- 
tions are  therefore  most  effective  when  made  in  a  small  room  with 
closed  windows.] 

The  buccal  route,  for  a  long  time  the  most  generally  used,  also 
has  its  disadvantages:  uncertainty  as  to  the  actual  penetration  of 
the  dose  into  the  tissue-juices,  low  effectiveness  and  lasting  digestive 
disturbances;  the  latter  attract  little  attention  on  acount  of  their 
delayed  appearance,  but  occur  almost  infallibly  in  patients  who  have 
been  treated  for  a  long  time. 

Use  is  made  either  of  van  Swieten's  fluid,  4  to  6  teaspoonfuls 
daily  in  a  little  milk,  or  Dupuytren's  pills  (bichloride  of  mercury  and 
extract  of  opium  aa  00.1,  excipient  and  glycerine  q.  s.  for  1  soft  pill) 
or  especially  Ricord's  pills  (protoiodide  of  mercury  0.05,  extract  of 
opium  0.01,  excipient  and  glycerine  q.  s.)  to  be  taken  at  meals,  in 
a  dose  of  2  pills  daily  for  an  adult,  1|  for  a  woman. 

The  rectal  route  may  be  utilized.    Audry  recommended  supposi- 


634  INFECTIOUS  DERMATOSES  DUE  TO  PROTOZOA 

tories  of  cacao  butter  with  an  addition  of  40  per  cent,  gray  oil,  in 
such  a  proportion  as  to  contain  0.02  to  0.04  of  metallic  mercury; 
this  method  is  slow  in  its  action. 

Mercurial  injections  are  at  present  one  of  the  fundamental  methods 
of  treatment  of  syphilis.  They  insure  a  strict  dosage,  exclude  fraud 
or  negligence  on  the  part  of  the  patient,  spare  the  digestive  apparatus 
and  when  properly  applied  and  well  tolerated  are  found  to  be  almost 
as  rapidly  effective  as  arsenical  medication.  At  the  present  writing, 
I  regard  mercurial  injections  as  an  indispensable  complement  of 
treatment  with  the  arsenobenzols.  Further  on  I  shall  point  out 
how  the  two  medications  may  be  combined. 

Mercurial  injections  are  made  in  the  region  of  the  buttocks. 
The  pain  of  the  puncture  is  practically  zero,  abscesses  are  no  longer 
to  be  feared,  pain  coming  on  after  the  injection  is  insignificant 
provided  the  technic  is  correct  and  nodosities  are  rare  and  usually 
painless.  On  the  whole,  the  drawbacks  of  the  method  cannot  be 
compared  with  its  advantages. 

The  technic  is  now  definitely  established  and  the  following  rules 
must  be  observed:  The  necessary  implements  are  a  needle  from 
6  to  7  cm.  long,  preferably  of  iridium-platinum  and  an  accurately 
divided  sterilizable  syringe  made  entirely  of  glass;  the  whole  outfit 
is  first  to  be  boiled.  The  puncture-points  are  selected  as  follows: 
(1)  On  a  horizontal  line  passing  three  or  four  fingers'  width  below 
the  iliac  crest;  (2)  on  a  vertical  line  passing  two  fingers'  width  from 
the  intergluteal  fold.  It  is  advisable  to  begin  with  the  left  buttock 
and  to  inject  on  the  two  sides  alternately,  of  course  avoiding  the 
previously  punctured  points.  The  patient  lies  on  the  abdomen,  with 
complete  muscular  relaxation;  the  area  selected  is  cleaned  with  a 
cotton  wipe  soaked  in  benzine,  ether  or  alcohol.  The  needle  is 
plunged  in  vertically  with  a  clean  thrust  and  a  minute  is  allowed  to 
pass,  in  order  to  be  sure  that  no  drop  of  blood  flows  through  its 
lumen;  should  this  happen,  the  needle  will  have  to  be  [partlyl 
withdrawn  and  inserted  elsewhere,  to  guard  against  embolism; 
otherwise,  the  syringe  containing  the  desired  dose  is  adjusted  [and 
the  fluid  slowly  injected];  at  the  end  of  the  procedure,  a  drop  of 
collodion  or  a  piece  of  plaster  is  placed  over  the  puncture-orifice. 

Mercurial  injections  are  administered  with  insoluble  compounds 
or  with  soluble  salts. 

The  former  have  the  advantage  of  being  applicable  at  longer 
intervals,  usually  once  a  week.  The  soluble  injections  must  be 
repeated  every  day,  causing  a  loss  of  time  and  much  inconvenience 
outside  of  hospital  practice;  they  have  a  powerful  and  rapid,  but 
less  durable  effect. 

Gray  oil  is  the  most  practical  insoluble  injection.  The  formula 
of  the  Codex  for  1908  contains:  purified  mercury,  40  grams;  lano- 


SYPHILIS  635 

line,  26  grams;  vaseline  oil,  60  grams;  1  c.c.  contains  0.4  gm.  of 
mercury.  This  preparation  is  employed  luke-warm,  using  a  syringe 
of  narrow  caliber  [tuberculin  syringe];  0.07  to  0.12  Hg  weekly 
should  be  injected  into  a  man  and  0.06  to  0.10  into  a  woman. 

Calomel  injections  are  much  more  energetic  and  efficient;  their 
action  is  nearly  as  rapid  as  that  of  arsenobenzol.  They  are  often 
alone  sufficient  to  cure  certain  lesions,  such  as  the  obstinate  palmar 
syphilides  and  the  tertiary  lesions  of  the  tongue.  The  dose  to  be 
injected  is  from  0.05  to  0.10  (or  1  c.c.  of  the  formula:  calomel  (by 
vaporization)  0.5  or  1.0,  vaselin  and  vaselin  oil,  aa  5  grams). 
Their  drawback  consists  in  the  sometimes  severe  but  as  a  rule  quite 
tolerable  pain  caused  by  them.  This  is  largely  obviated,  as  I  have 
suggested,  by  adding  per  1  c.c,  0.03  of  guaiacol  and  0.02  of  cam- 
phor. The  same  addition  is  advantageously  made  to  gray  oil  and 
to  the  other  insoluble  injections. 

The  basic  salicylate  of  mercury  (0.10  per  injection),  or  yellow 
oxide  (0.05  to  0.10)  may  be  substituted  for  gray  oil,  without,  how- 
ever, being  preferable  to  it. 

[With  all  the  mercurial  suspensions  in  oil,  it  would  seem  physio- 
logically preferable  to  use  olein  (ol.  olivarum)  rather  than  foreign 
bodies  like  the  paraffins  (vaseline,  vaseline  oil,  etc.).  Furthermore, 
the  larger  the  volume  of  the  injected  mass  the  greater  the  pain.  I 
employ  calomel  in  20  per  cent,  suspension  and  the  salicylate  in  33 
per  cent,  suspension,  injecting  a  proportionately  smaller  amount 
of  fluid.] 

Soluble  injections  are  made  with  benzoate  of  mercury  according 
to  the  formula  of  Gaucher;  with  bibromide  or  biniodide  of  mercury, 
or  with  the  cyanide.  The  daily  dose  is  from  0.01  to  0.03  of  each  of 
these  salts;  the  pain  is  generally  moderate.  Bichloride  of  mercury 
is  more  painful  and  should  be  rejected  for  this  reason.  Tolerance 
varies  greatly  according  to  the  patients  and  it  is  advisable  to  look 
in  each  particular  case  for  the  most  readily  tolerated  formula. 
Various  preparations  of  mercury  disguised  under  proprietary  names 
(hermophenyl,  enesol,  etc.),  are  not  sufficiently  reliable  in  their 
action. 

Intravenous  injections  of  soluble  salts  may  also  be  recommended ; 
the  cyanide  of  mercury  alone  is  used  for  the  same  [the  bichloride 
is  also  employed].  They  are  entirely  painless  and  very  promptly 
efficient.     [They  are  administered  in  normal  saline  solution.] 

Local  mercurial  treatment  of  syphilides,  especially  the  tertiary 
manifestations,  is  entirely  reasonable;  it  serves  as  an  adjuvant  of  the 
general  medicinal  treatment  and  prior  to  the  era  of  arsenobenzol 
injections  was  recommended  by  me  in  those  cases  where  the  patient's 
buccal  or  intestinal  condition  prevented  an  energetic  general  mer- 
curialization.  I  have  been  well  pleased,  especially  in  the  treatment  of 


636         INFECTIOUS  DERMATOSES  DUE  TO  PROTOZOA 

circumscribed  leukoplakias  and  leukoplasic  ulcer,  with  local  injec- 
tions of  a  few  drops  of  an  isotonic  cyanide  solution  of  1  to  3000 
(formula:  cyanide  of  mercury,  0.3.'!;  cocain  chlorhydrate,  .">.(); 
sodium  chloride,  7.0;  sterilized  water,  1  liter)  repeated  twice  weekly. 
The  traditional  mercurial  plaster,  salves  and  mercurial  baths  are  no 
longer  indicated  at  the  present  time. 

Mercurial  complications,  hydrargyria  are  possible  with  all  com- 
pounds, all  formulas  and  all  methods  without  exception.  Their 
possible  occurrence  renders  it  necessary  first  to  test  the  patient's 
sensibility  and  always  to  proceed  with  caution. 

Mercurial  stomatitis  was  a  distressing  and  formidable  symptom 
in  the  days  when  salivation  was  systematically  aimed  at.  The 
present  tendency  is  to  consider  it  as  due  to  the  fuso-spirillary  asso- 
ciation and  induced  by  the  irritation  of  the  mouth.  Its  development 
may  be  prevented  by  putting  the  mouth  in  good  condition  before 
beginning  the  treatment  and  by  maintaining  great  cleanliness. 
The  use  of  tobacco  must  be  interdicted.  The  gastro-intestinal 
apparatus  likewise  requires  continuous  supervision.  Finally,  the 
urine  must  be  watched. 

Arsenic. — Arsenic  in  all  its  forms  had  long  been  advocated  as  an 
adjuvant  of  mercurial  treatment;  sodium  arsenate,  the  cacodylates, 
methylarsenate,  hectargyrium  and  other  preparations  have  served 
for  this  purpose. 

Since  a  dozen  years,  however,  a  direct  specific  medication  has  been 
sought  in  new  arsenical  compounds.  Atoxyl  and  arsacetine  were 
promptly  abandoned  as  too  dangerous.  The  "  hectine"  of  Mouneyrat 
has  enjoyed  a  certain  popularity,  but  this  product  does  not  seem 
to  me  to  be  better  than  a  good  adjuvant. 

In  the  course  of  his  investigations  on  the  arsenic  treatment  of  the 
spirilloses,  Ehrlich  in  1909  stopped  at  a  compound,  the  dichlor- 
hydrate  of  dioxydiamido-arsenobenzol,  wrhich  was  numbered  606; 
this  product  was  labelled  with  the  name  of  salvarsan;  at  the  present 
writing  it  is  manufactured  everywhere  and  known  as  arsenobenzol. 
[In  the  United  States  the  official  name  since  1917  is  arsphenamine.) 
Shortly  afterward  he  recommended  a  related  product,  much  more 
convenient  to  employ,  the  dioxydiamido-arsenobenzol-monomethy- 
lene-sulfoxylate  of  sodium,  or  914,  or  neosalvarsan,  which  is  cus- 
tomarily designated  by  the  name  of  novarsenobenzol  for  neo- 
arsphenamine].  Other  more  or  less  analogous  arsenical  salts,  notably 
galyl,  luargol,  etc.,  have  been  produced  and  tried  in  France;  these 
investigations  are  still  under  way. 

Briefly,  arsenobenzol  and  novarsenobenzol  constitute  the  anti- 
syphilitic  arsenical  medication  of  the  present  day.1 

1  Wherever  treatment  with  arsenobenzol,  or  the  arsenobenzols,  has  been  referred 
to  in  the  course  of  this  hook,  I  have  meant  intravenous  injections  with  arsenobenzol 
or  witli  novarsenobenzol  [arsphenamine  or  neo-arsphenamine]. 


SYPHILIS  637 

The  hope  which  had  been  aroused  of  a  "therapia  sterilisans 
magna,"  a  radical  and  rapid  cure  of  syphilis  has  not  been  realized; 
it  must  be  abandoned  and  doses  employed  which  do  not  expose  to 
the  gravest  risks.  Nevertheless,  the  efficacy  of  arsenobenzol  and 
almost  to  the  same  degree  of  novarsenobenzol  is  not  less  remarkable; 
in  a  few  days  they  will  cicatrize  a  chancre,  obliterate  roseola  or 
mucous  patches;  when  employed  in  the  primary  stage  and  especially 
in  combination  with  mercurial  injections,  they  almost  certainly 
protect  against  all  secondary  manifestations  and  usually  maintain  a 
permanently  negative  Wassermann  reaction.  The  test  of  time  is 
not  yet  sufficient  to  state  that  patients  treated  in  this  way  will 
remain  free  from  tertiary  and  parasyphilitic  lesions.  While  this 
may  be  hoped  for,  it  is  advisable  to  complete  the  treatment  with 
mercury  for  the  present.  At  any  rate,  the  dangers  of  contagion  are 
immeasurably  diminished  in  these  "silenced"  cases  of  syphilis  and  it 
is  needless  to  dwell  upon  the  social  importance  of  this  result. 

The  manipulation  of  the  new  arsenical  compounds  is  difficult; 
their  employment  cannot  be  said  to  be  absolutely  devoid  of  danger; 
especially  in  the  early  days,  serious  and  even  fatal  results  have  been 
noted.  Better  regulated  doses  and  extreme  precautions,  however, 
have  reduced  the  risks  of  this  treatment  to  a  minimum. 

There  is  a  practically  general  agreement  as  to  their  administra- 
tion only  by  the  venous  route.  Those  who  have  witnessed  the  intol- 
erable pains  and  fearful  sloughs  which  were  often  produced  by 
intramuscular  injections  of  606,  such  as  were  originally  administered, 
have  abandoned  them  altogether.  Balzer  and  Dumouthiers  advo- 
cated intramuscular  injections  of  novarsenobenzol  in  doses  of 
0.25,  twice  daily.  These  are  often  not  particularly  painful,  have  a 
slower  action  and  are  only  rarely  indicated.  Nowadays,  every 
physician  should  be  familiar  with  the  technique  of  intravenous 
injections. 

Arsenobenzol  is  the  most  active  and  the  most  permanently  steriliz- 
ing antisyphilitic  remedy  known.  Its  watery  solution  is  acid  and 
must  be  neutralized  or  rendered  slightly  alkaline  by  the  addition  of 
a  sodic  hydrate  solution,  then  diluted  with  physiological  salt  solu- 
tion of  7  per  1000,  prepared  with  pure  sodium  chloride  dissolved  in 
freshly  distilled  water;  the  total  amount  to  be  injected  is  according 
to  some  writers  from  150  to  200  c.c,  according  to  others  50  c.c.  for 
each  0.10  of  the  remedy. 

Nov-arsenobenzol  is  generally  preferred  on  account  of  the  relatively 
simple  instrumentation  and  mode  of  preparation  of  the  solution, 
especially  when  the  very  convenient  procedure  of  intravenous  injec- 
tions in  concentrated  solution  of  Ravaut  is  adopted  and  carried  out 
as  follows:  Immediately  before  it  is  to  be  used  the  contents  of  a 
nov-arsenobenzol  ampoule  is  dissolved  in  5  to  10  c.c.  of  physiological 


38  INFECTIOUS  DERMATOSES  DUE  TO  PROTOZOA 

salt  solution,  4  per  1000,  or  the  same  quantity  of  distilled  water  or 
even  freshly  boiled  and  cooled  water  may  be  employed.  Solution 
is  instantaneous;  the  solution  is  drawn  into  an  all-glass  sterilized 
syringe,  provided  with  a  short-bevelled  platinum  needle;  the  patient 
lies  down  and  the  arm  is  put  on  the  stretch ;  the  needle  is  now  inserted 
into  a  vein  at  the  bend  of  the  elbow  which  has  been  made  prominent 
by  applying  a  rubber  band  on  the  arm;  when  the  blood  flows  back 
into  the  syringe  indicating  that  the  needle  is  properly  inserted,  the 
band  is  removed  from  the  arm  and  the  piston  is  gently  pushed  in; 
after  the  injection  has  been  made  and  the  needle  is  withdrawn,  no 
dressing  is  required.  [The  field  of  operation  must,  of  course,  have 
been  sterilized  with  alcohol  or  a  weak  solution  of  iodine.] 

Some  precautions  are  needed  with  all  arsenical  compounds.  In 
case  of  virulent  syphilis,  with  multiple  manifestations,  it  is  advisable 
to  treat  the  patient  for  two  or  three  days  before  the  arsenical  injec- 
tion, with  injections  of  a  soluble  mercury  salt;  this  guards  against 
an  attack  of  fever  with  malaise,  known  under  the  name  of  Herx- 
heimer's  reaction  and  attributed  to  the  sudden  absorption  of  the 
products  resulting  from  a  large  number  of  disintegrated  spirochetes. 
The  patient  must  fast  three  hours  before  and  five  hours  after  the 
injection.  Examination  of  the  urine  just  before  the  injection  is 
indispensable,  so  as  to  permit  a  diminution  of  the  dose  or  its  post- 
ponement to  a  later  date,  in  case  albumin  is  present.  The  ampoule 
must  be  carefully  examined  to  see  that  its  contents  consist  of  a 
light  yellow  powder,  unaltered  by  penetration  of  air. 

As  a  rule  no  reaction  of  any  kind  follows.  It  is  advisable,  however, 
to  warn  the  patient  of  the  possible  onset  of  certain  symptoms,  such 
as  headache,  mild  diarrhea,  a  chill  with  a  slight  ephemeral  fever, 
general  prostration,  nausea,  sometimes  vomiting,  rarely  an  erythe- 
matous eruption;  he  will  be  so  much  the  more  pleased  should  these 
symptoms  fail  to  make  their  appearance. 

Threatening,  grave  and  even  fatal  complications,  the  mechanism 
of  which  has  been  extensively  discussed,  have  been  observed  espe- 
cially with  arsenobenzol,  more  particularly  at  the  time  of  the  first 
ventures;  they  have  become  extremely  rare  since  the  doses  are  more 
carefully  regulated  [the  quality  of  the  arsphenamine  improved  and 
more  attention  paid  to  the  preparation  of  the  patient].  A  purplish 
swelling  of  the  face,  in  the  course  of  an  over-rapid  injection,  known 
as  "nitritoid  crisis,"  may  be  efficiently  controlled,  as  shown  by 
Milian,  through  injections  of  |  mg.  of  adrenalin,  which  exerts  a 
a  preventive  effect.  In  case  the  injection  be  followed  in  the  next 
few  hours  or  the  first  days  by  convulsions  or  delirium  or  spasms 
with  a  tendency  to  coma,  a  profuse  venesection  should  at  once  be 
preformed,  adrenalin  should  be  injected,  a  spinal  puncture  made 
and    intravenous    irrigations    with    physiological    salt   solution  be 


SYPHILIS  639 

administered.  The  employment  of  these  measures  has  proved  suc- 
cessful in  very  alarming  cases,  which,  let  me  repeat,  are  of  altogether 
exceptional  occurrence. 

Auxiliary  Medication. — Potassium  iodide,  introduced  into  the 
treatment  of  syphilis  by  Wallace  and  by  Ricord,  for  a  long  time 
advocated  as  a  specific  in  tertiary  lesions,  has  lost  much  of  the  favor 
it  formerly  enjoyed,  especially  since  the  introduction  of  arseno- 
benzol  and  since  it  has  been  shown  to  have  no  influence  on  the 
Wassermann  reaction.  It  may  be  described  as  not  indispensable. 
In  the  secondary  stage,  in  daily  doses  of  1  to  3  grams,  it  serves  to 
control  the  headache  and  the  painful  manifestations.  In  the  ter- 
tiary stage,  it  is  used,  combined  with  mercury  in  doses  of  4  to  12 
grams,  to  stimulate  the  healing  of  sluggish  lesions  and  against  the 
lesions  of  the  nervous  system  or  the  viscera.  Its  employment  should 
be  avoided,  however,  in  the  treatment  of  so-called  parasyphilitic 
disorders  (general  paralysis,  tabes,  etc.)  and  in  the  case  of  laryngeal 
symptoms.  In  subcutaneous  injections  it  is  too  painful,  but  it  may 
be  administered  in  enemas  [and  has  been  given  intravenously;  but 
this  seems  to  me  a  futile  procedure].  Other  iodide  compounds 
besides  potassium  iodide  are  of  less  efficiency. 

Some  authors  prescribe  as  a  routine  procedure  a  mixed  iodo- 
mercurial  syrup,  of  the  type  of  Gibert's  syrup;  it  is  better  to  admin- 
ister the  two  medicinal  agents  separately,  Sulphur  medication, 
cod-liver  oil,  rarely  iron,  more  frequently  hydrotherapy,  cures  at 
watering-places  with  warm  mineral  springs,  such  as  Luchon,  Uriage, 
la  Bourboule,  Amelie-les-Bains  [or  Hot  Springs],  or  sodium  chloride 
springs,  may  prove  of  the  greatest  value  for  the  improvement  of 
the  patient's  general  condition  or  his  tolerance  of  mercurialization. 

It  is  always  necessary  to  watch  the  alimentary,  physical,  occupa- 
tional and  emotional  hygiene  of  syphilitic  patients,  cutting  out 
especially  the  abuse  of  alcohol,  venereal  excesses,  late  hours,  and 
overstrain  of  all  kinds.  A  moderate  use  of  tobacco  may  be  permitted, 
except  at  times  where  the  production  of  buccal  mucous  patches  is 
threatened  or  when  it  seems  to  favor  the  onset  of  mercurial  stomatitis. 

General  Conduct  of  the  Treatment. — The  so-called  abortive  treat- 
ment of  MetchnikofT  consists  of  rubbing  without  delay  a  calomel 
salve,  1  to  3,  into  the  mucous  membrane  or  an  erosion  which  has 
been  exposed  to  syphilitic  contact.  Although  it  has  been  experi- 
mentally tested  in  monkeys,  this  procedure  is  not  free  from  dis- 
advantages and  has  not  been  demonstrated  to  be  superior  to  simple 
washing  with  soap  and  water.  [Prophylactic  treatment  after 
venereal  exposure  is  obligatory  in  the  United  States  army.  An 
experience  based  on  several  hundred  thousand  cases  shows  that  the 
MetchnikofT  inunctions  applied  within  six  hours  after  exposure  are 
a  practically  certain  preventive  of  infection.] 


640  INFECTIOUS   DERMATOSES  DUE  TO  PROTOZOA 

Early  excision  of  the  chancre  is  certainly  not  capable,  as  had  been 
believed,  of  bringing  about  an  eradication  of  syphilis;  when  the 
operation  is  possible  without  producing  deformities,  some  authors 
have  found  it  useful,  but  there  is  nothing  to  show  that  it  modifies 
the  gravity  of  the  infection. 

A  fundamental  rule,  which  must  never  be  slighted,  is  as  follows: 
Never  begin  specific  treatment  before  the  diagnosis  has  been  positively 
established:  this  would  be  a  serious  error,  which  before  long  would 
inevitably  lead  to  insuperable  difficulties. 

When  the  diagnosis  is  definitely  established,  the  general  specific 
treatment  must  at  once  be  instituted,  taking  care  at  the  same  time 
of  the  local  lesions  and  guarding  against  contagion.  Recent  experi- 
ence has  shown  the  great  importance  of  a  vigorous  offensive,  striking 
hard  and  strong,  at  least  in  the  primary  stage.  In  all  stages  of  the 
disease,  we  must  aim  not  only  at  extinguishing  the  actual  manifes- 
tations, at  "bleaching  the  syphilitic"  to  use  a  French  expression, 
but  at  completely  stamping  out  the  virulence  of  the  disease  and 
safeguarding  the  future — aims  which  are  usually  attainable. 

The  problems  dealing  with  the  general  conduct  of  the  treatment 
have  been  reawakened  by  the  introduction  of  the  arsenical  medica- 
tion. The  era  of  trials  and  discussions  is  not  yet  past,  so  that  no 
detailed  and  definite  rules  can  be  formulated.  1  shall  therefore 
restrict  myself  to  describing  my  actual  mode  of  procedure  and  that 
of  the  majority  of  experienced  syphilographers. 

It  is  quite  generally  agreed  to  begin  in  all  cases  with  a  medication 
which  although  cautious  must  be  as  energetic  as  the  patient  can 
tolerate;  and  to  continue  with  the  tried  and  approved  method  of 
chronic  intermittent  treatment. 

It  seems  to  me  highly  advantageous  to  begin  the  treatment  with 
novarsenobenzol  or  arsenobenzol.  These  remedies  are  positively 
indicated  for  patients  likely  to  contaminate  their  environment, 
married  persons,  those  expecting  to  be  married,  fathers  of  families, 
prostitutes,  etc. ;  or  in  the  presence  of  malignant  symptoms  or  lesions 
of  a  destructive  character;  or  when  a  bad  condition  of  the  teeth, 
which  is  common,  or  of  the  intestinal  tract  suggests  that  mercury 
will  be  badly  tolerated;  or  in  tuberculous  patients  in  whom  the 
breaking  down  of  tubercles  is  favored  by  mercury.  Inversely,  these 
remedies  should  be  omitted  or  very  cautiously  employed  in  cases 
of  cerebrospinal,  meningeal,  renal,  cardiovascular  or  hemorrhagic 
manifestations;  under  these  conditions,  it  is  preferable  to  rely  exclu- 
sively   upon    soluble   mercurial   injections. 

In  a  general  way,  in  the  absence  of  contra-indications,  I  consider 
it  advisable  to  give  at  first  about  5  or  6  injections  of  novarseno- 
benzol at  a  week's  interval  (not  less  than  four  and  very  exception- 
ally more  than   seven)  in  progressive  doses   (of  0.30;  0.45;  0.60; 


SYPHILIS  641 

0.75;  0.90);  in  case  of  arsenobenzol  the  doses  are  one-third  smaller 
and  it  is  better  not  to  go  above  0.50.  In  this  increasing  dosage,  it 
is  of  course  necessary  to  take  into  consideration  the  signs  of  possible 
intolerance,  the  strength  of  the  patient,  the  character  and  more  or 
less  obstinate  behavior  of  the  symptoms. 

Next,  after  a  few  weeks  of  rest,  mercurial  treatment  is  begun  with 
soluble  injections  in  a  series  of  20  to  30  every  two  or  three  months; 
or,  as  seems  preferable  to  me,  with  injections  of  gray  oil,  in  strong 
doses,  in  series  of  6 ;  three  of  these  series  in  the  course  of  each  of  the 
first  two  years,  another  two  or  three  series  in  the  course  of  the  third 
and  again  in  the  fourth  year,  appear  to  be  a  treatment  capable  of 
providing  adequate  security. 

The  question  has  been  raised  why  the  two  powerful  antisyphilitic 
agents  in  our  possession,  arsenic  and  mercury,  should  not  be  simul- 
taneously employed  from  the  start.  As  a  matter  of  fact,  this  com- 
bined treatment — which  consists  in  applying  during  the  first  series 
of  novarsenobenzol  injections,  4  or  5  soluble  mercurial  injections 
in  the  intervening  days — is,  as  a  rule,  very  readily  tolerated  by  robust 
individuals,  in  spite  of  the  theoretical  fears  which  have  been  enter- 
tained; stomatitis  and  albuminuria  are  of  rare  occurrence. 

It  is  assuredly  rational  and  advantageous,  especially  in  the  pres- 
ence of  some  special  indication  (positive  Wassermann  reaction)  to 
interpolate  in  the  course  of  the  second  to  fourth  year,  one  or 
two  series  of  novarsenobenzol  injections  between  the  mercurial 
treatments. 

The  same  procedure,  combined  or  alternating  medication,  may 
be  adopted  in  the  treatment  of  late  secondary  lesions  or  tertiary 
manifestations. 

One  of  the  most  mooted  questions  is  that  of  the  part  played  by 
the  Wassermann  reaction  in  the  conduct  of  the  treatment.  Some 
allow  themselves  to  be  guided  to  a  large  extent  by  the  modifications 
of  the  Wassermann  reaction  of  the  bloodserum,  periodically  tested 
every  three  months  for  instance.  Some  even  go  so  far  as  to  follow 
systematically  the  indications  furnished  by  the  reaction  of  the  cere- 
brospinal fluid.  Others  go  too  far  in  the  opposite  direction  and  dis- 
claim all  indicative  value  of  these  reactions  for  the  treatment.  In 
my  opinion,  this  factor  should  be  kept  in  mind,  but  to  be  guided 
by  the  serum-reaction  alone  would  result  either  in  abbreviated 
treatments  when  it  remains  negative,  or  to  unduly  prolonged  or 
dangerously  increased  medications  in  case  it  remains  positive.  It 
is  a  matter  of  judgment  and  clinical  sense. 

From  a  very  elaborate  review  of  this  question,  Hudelo,  writing  in 

Paris  Medical,  May  5,  1917,  concludes  that  the  following  procedure 

is  to  be  recommended :    At  the  beginning,  administer  8  or  9  injections 

of  nov-arsenobenzol  at  five-day  intervals  until  a  total  of  4  to  5  grams 

41 


642  INFECTIOUS  DERMATOSES  DUE  TO  PROTOZOA 

has  been  given,  interpolating  twenty  injections  of  0.01  of  a  soluble 
mercury  salt.  After  six  weeks  to  two  months,  if  the  Wassermanu 
test  of  the  blood  is  negative,  injections  of  soluble  mercury  salts  are 
to  be  given  for  six  months,  10  each  month,  or  20  every  two  months; 
if,  on  the  contrary,  the  Wassermann  reaction  again  becomes  positive, 
repeat  the  combined  treatment  of  the  first  forty  days.  At  the  end 
of  the  first  period  of  six  months,  a  spinal  puncture  is  made;  if  it 
reveals  an  abnormal  condition  (hypertension,  albuminosis,  lympho- 
cytosis, positive  Wassermann),  the  duration  of  the  intervals  of  rest 
must  be  reduced  or  a  prolonged  combined  treatment  be  resumed; 
when  clinical  symptoms  are  present  (headache,  etc.),  the  doses 
should  be  diminished,  but  the  series  be  prolonged,  as  recommended 
by  Ravaut.  At  the  end  of  the  sixth  month,  administer  a  series  of  20 
soluble  mercury  injections,  or  of  6  injections  of  gray  oil,  every  three 
months  until  the  completion  of  the  second  year;  every  four  months 
during  the  third;  every  six  months  in  the  fourth  and  in  the  fifth 
year.  The  Wassermann  reaction  should  be  verified  about  once  in 
four  months. 

In  all  probability,  the  new  methods  of  specific  treatment  will 
permit  an  abbreviation  of  the  time-honored  delay  of  four  or  five 
years  expected  from  syphilitics  who  are  contemplating  marriage. 
It  is  advisable,  however,  while  taking  into  consideration  the  thor- 
oughness of  the  treatment  and  the  serum-reaction,  not  to  depart 
too  far  from  the  limits  established  by  long  experience;  as  heretofore, 
the  recommendation  of  a  course  of  treatment  with  gray  oil  shortly 
before  marriage  is  sound  advice. 

[As  the  author  has  well  said,  the  period  of  trials  and  discussions  has  not 
yet  passed.  I  need  make  no  apology  for  entertaining  very  different  views 
in  regard  to  the  administration  of  arsphenamine  and  I  have  little  hesitation 
in  presenting  them  even  at  the  risk  of  some  repetition  because  it  is  desirable 
that  the  reader  become  acquainted  with  other  views.  The  final  verdict  on 
this  subject  belongs  to  the  future. 

Principles  of  Treatment. — The  fact  is  indisputable  that  many  cases  of 
syphilis  have  been  cured  by  a  single  course  of  injections  of  arsphenamine 
or  even  by  a  single  injection  in  the  first  weeks  after  infection.  In  the  later 
stages  it  requires  prolonged  treatment  with  many  courses  to  bring  about 
a  permanent  Wassermann  reaction.  This  difference  probably  depends 
on  two  factors:  the  spirochetes  have  become  localized  in  regions  where 
thejr  are  not  readily  reached  by  the  arsphenamine  or  they  have  assumed  a 
form  in  which  they  are  resistant  to  the  drug,  an  encysted  or  spore  form. 

To  meet  the  indications  arising  from  the  possibility  of  resistant  forms  we 
employ  the  interrupted  method  of  sterilization,  the  method  which  long 
experience  has  shown  to  be  the  best  with  mercury  as  the  laboratory  has 
shown  it  to  be  the  best  and,  depending  on  the  medium,  often  the  only  pos- 
sible method  of  sterilization.  Periods  of  treatment  must  alternate  with 
periods  of  rest  during  which  the  organisms  may  emerge  from  their  resistant 
stage  in  order  that  our  sterilizing  agents  may  again  successfully  attack  them 
in  their  developed  form. 


SYPHILIS  643 

To  meet  the  indications  derived  from  the  possibility  of  remote  or  inacces- 
sible localization  of  spirochetes  it  is  necessary  to  employ  the  drug  in  such 
dosage  and  to  maintain  the  saturation  of  the  blood  with  it  for  such  periods 
that  even  the  tissues  least  well  supplied  with  a  circulating  fluid  will  receive 
an  adequate  amount  of  arsphenamine  to  kill  the  germs. 

We  employ  the  soluble  salts  of  mercury  in  daily  doses  because  we  aim 
at  maintaining  a  fairly  constant  amount  of  mercury  in  the  system  during 
the  period  of  treatment.  We  give  the  insoluble  compounds  of  mercury  in 
weekly  doses  because  with  their  slower  elimination  we  accomplish  the 
same  result  with  less  frequent  injections.  In  rapidity  of  elimination, 
arsphenamine  is  comparable  to  the  soluble  salts  of  mercury.  At  the  end 
of  twenty-four  hours  only  a  small  fraction  of  the  quantity  injected  remains 
in  the  system.  To  maintain  a  saturation  of  the  system  for  a  considerable 
period  it  would  be  necessary  to  administer  arsphenamine  in  daily  doses. 
This  result,  however,  would  not  be  advantageous  even  if  it  were  technically 
feasible  because  arsphenamine,  so  far  as  we  know,  acts  simply  as  a  spiro- 
cheticide  and  a  single  injection  of  the  drug  kills  all  the  spirochetes  which 
it  can  reach  in  adequate  dosage.  There  are  no  spirochetes  left  in  the  blood 
to  be  acted  on  by  the  arsphenamine  administered  within  the  next  day  or 
two;  it  is  only  after  the  lapse  of  a  longer  time  that  we  can  again  expect  to 
find  free  spirochetes  in  the  blood.  But  the  repetition  of  the  dose  at  short 
intervals  for  a  few  days  serves  to  maintain  a  degree  of  saturation  of  the 
system  with  the  drug  which  makes  it  possible  for  the  arsphenamine-laden 
fluids  to  reach  remote  and  outlying  regions  in  sufficient  dosage. 

The  principles  on  which  my  arsphenamine  treatment  of  syphilis  are 
based  are  therefore : 

1.  The  principles  of  interrupted  sterilization  to  destroy  the  resistant 
forms. 

2.  The  principle  of  prolonged  saturation  to  reach  and  destroy  the  remote 
or  deeply  hidden  germs. 

Arsphenamine  is  now  made  in  many  chemical  factories  in  different 
countries.  The  different  products  are  by  no  means  equally  free  from 
impurities  which  cause  immediate  or  later  reactions.  Some  of  these  products 
are  followed  by  dangerous  reactions  in  a  large  percentage  of  cases;  some  are 
far  more  free  from  these  dangers  even  than  was  the  original  606.  The  general 
practitioner  must  choose  his  arsphenamine  in  accordance  with  the  experience 
of  those  specialists  who  have  larger  opportunities  for  acquaintance  with 
the  different  brands.  The  question  of  cost  or  of  convenience  in  preparation 
should  have  no  weight  in  dealing  with  so  potent  a  drug  and  so  grave  a 


Dosage,  Preparation  of  Solution  and  of  Patient.  The  dose  should  be 
proportioned  to  the  weight  of  the  patient,  making  some  allowance  for  sex 
and  a  physical  condition  possibly  weakened  by  disease,  alcoholism,  etc. 
A  dose  equal  to  0.1  for  each  twenty-five  pounds  of  body  weight  is  the  dose 
for  a  man;  0.1  to  thirty  pounds  of  weight  for  a  woman  or  a  child;  and  half 
that  amount  for  an  infant.  With  an  otherwise  healthy  patient  the  first 
dose  should  not  be  less  than  the  full  dose.  The  employment  of  a  small 
initial  dose  followed  once  a  week  by  slightly  larger  doses  is  open  to  the  grave 
objection  that  such  a  procedure  is  likely  to  encourage  the  development  of 
arsenic-resistant  spirochetes.  The  rise  in  temperature  that  usually  follows 
the  first  injection  in  florid  syphilis  is  of  no  serious  consequence. 

For  the  preparation  of  the  solution  it  is  not  necessary  to  employ  a  normal 
salt  solution.  Freshly  distilled  and  sterilized  water  in  the  proportion  of 
20  c.c.  of  water  for  each  0.1  of  arsphenamine  is  a  convenient  solution. 
Higher  concentrations,  15  c.c.  or  10  c.c.  of  water  to  each  0.1  of  drug  may  be 


044         INFECTIOUS  DERMATOSES  DUE  TO  PROTOZOA 

used  it'  the  needle  be  of  very  small  caliber  so  that  the  rate  of  flow  is  lessened; 
but  there  is  no  advantage  in  this  arrangement.  The  drug  must  be  com- 
pletely dissolved  before  the  alkali  is  added  and  the  alkalinization  should 
be  made  rapidly  and  exactly.  For  each  0.11  of  arsphenamine  a  little  less 
than  1  c.c.  of  a  lo  per  cent,  sodic  hydrate  should  be  added  in  a  stream  and 
the  remaining  few  drops  necessary  for  clearing  the  solution  added  slowly 
so  that  the  solution  is  decidedly  alkaline  but  without  needless  excess  of 
alkali.  The  solution  is  filtered  through  sterile  cotton  or  gauze  into  the 
burette  or  irrigator  which  is  to  be  suspended  or  held  about  three  feet  above 
the  point  on  the  patient's  arm  selected  for  the  injection.  The  rate  of  flow 
is  an  important  factor  in  the  production  of  nervous  and  vascular  reactions; 
the  needle  should  not  be  larger  than  20  gauge;  the  rate  of  flow  should  not 
greatly  exceed  0.1  of  arsphenamine  per  minute;  the  injection  of  a  full  dose 
should  require  about  five  minutes. 

An  examination  of  the  patient's  renal  function  should  always  precede  an 
injection  of  arsphenamine.  In  the  presence  of  a  marked  nephritis,  the  dose 
of  arsphenamine  must  be  reduced  to  one-quarter  or  one-sixth  the  normal 
dose  and  the  effect  on  the  kidneys  watched.  It  is  possible  that  the  nephritis 
is  syphilitic  and  that  its  symptoms  will  improve  after  the  arsphenamine. 
In  general,  arsphenamine  does  very  little  harm  to  the  kidneys,  certainly 
less  than  a  prolonged  course  of  mercury.  It  is  common  to  find  a  trace  of 
albumin  and  a  number  of  renal  casts  in  the  urine  the  day  following  an 
injection.  I  pay  no  attention  to  a  good  trace  of  albumin  or  a  moderate 
number  of  hyaline  casts  and  even  a  few  granular  casts.  But  a  considerable 
amount  of  albumin  and  many  granular  casts,  more  than  eight  or  ten  to  the 
slide,  or  epithelial  casts  may  be  a  contra-indication  to  immediate  further 
treatment.    These  cases  require  judgment  and  careful  consideration. 

The  night  before  beginning  the  course  of  treatment  the  patient  should 
receive  a  saline  purge.  If  the  treatment  is  to  be  administered  in  the  morning 
at  about  ten  o'clock,  he  is  permitted  to  take  nothing  more  than  a  cup  of  tea 
or  coffee  for  breakfast  before  eight  o'clock;  after  the  injection  he  fasts  for 
six  or  eight  hours  and  may  then  partake  of  a  moderate  dinner  avoiding 
heavy  and  indigestible  food.  If  the  injection  is  to  be  administered  at  two 
or  three  in  the  afternoon  the  patient  may  eat  his  customary  breakfast, 
but  should  restrict  his  luncheon  to  a  single  cup  of  tea  or  clear  broth  with  a 
small  piece  of  dry  toast,  not  later  than  twelve  o'clock;  he  fasts  for  six  or 
eight  hours  after  theinjection  and  may  partake  of  a  light  meal  before  retiring. 

A  course  of  arsphenamine  consists  of  an  intravenous  injection  of  a  full 
dose  of  arsphenamine  on  each  of  three  successive  days.  (A  course  of  com- 
bined treatment  consists  of  a  course  of  arsphenamine  followed  by  a  four 
to  six  weeks'  course  of  mercurial  injections.)  The  reactions  following  this 
energetic  treatment  with  arsphenamine  are  not  greater  than  those  that 
occur  after  a  single  injection.  In  fact,  it  is  only  the  first  of  the  three  injec- 
tions that  causes  whatever  reaction  may  occur.  If  the  first  injection  is 
followed  by  a  severe  reaction,  nitritoid  or  toxidermic,  it  would  be  folly  to 
give  another  the  next  day ;  but  these  severe  reactions  are  becoming  less  and 
less  frequent.  It  is  my  growing  belief  that  most  of  the  severe  reactions, 
assuming  a  reliable  arsphenamine,  are  due  to  faulty  technique:  improper 
preparation  of  the  patient,  inadequate  alkalinization  of  the  solution,  its 
too  great  concentration  or  too  rapid  administration. 

After  an  experience  of  nearly  five  years  with  this  method  I  can  state 
first,  that  it  is  as  safe  as  any  other  method  of  employing  arsphenamine;  and 
second,  that  its  results  are  greatly  superior  to  those  obtained  by  other 
met  hods  of  nsiiiji'  that  remedy.  In  these  statements  I  have  the  endorse- 
ment of  numerous  colleagues  who  have  had  experience  with  this  method. 


SYPHILIS  645 

Four  courses  of  the  combined  treatment  should  be  given  during  the  first 
year  after  infection,  irrespective  of  the  Wassermann  reaction.  The  intervals 
of  rest  between  the  courses  last  six  weeks  between  the  first  and  second  and 
eight  weeks  between  the  others.  If  the  patient  came  under  treatment 
before  the  appearance  of  secondary  lesions,  the  Wassermann  reaction  will 
probably  have  remained  negative  throughout  the  year  and  it  may  be  left 
to  the  judgment  of  the  physician  whether  or  not  the  treatment  be  continued 
or  the  patient  simply  kept  under  observation  during  the  next  two  or  three 
years  with  Wassermann  tests  every  three  to  six  months.  It  is  of  course 
safer  even  though  it  may  be  unnecessary  to  continue  treatment  during  the 
second  year  with  three  courses  of  combined  treatment  and  perhaps  two 
during  the  third  year.  In  the  present  state  of  our  knowledge  it  is  impossible 
to  say;  there  is  no  absolute  criterion  of  cure  except  a  re-infection.  But 
when  the  patient  has  remained  Wassermann-negative  for  a  year  without 
treatment  and  a  spinal  puncture  shows  no  involvement  of  the  central 
nervous  system,  he  may  be  discharged  as  probably  cured.  But  even  then 
he  should  be  examined  serologically  at  six  months'  intervals  for  several 
years.    Consent  to  marriage,  however,  may  be  given. 

The  syphilitic  who  comes  for  treatment  in  the  later  stages  of  his  disease 
should  receive  three  courses  of  combined  treatment  each  year  for  three 
years.  Cutaneous  manifestations  will  heal  in  a  few  weeks  at  most  under 
this  treatment  but  visceral  lesions  do  not  respond  so  favorably,  especially 
those  of  the  heart  and  aorta  and  the  central  nervous  system.  Many  of 
these  cases  do  not  become  permanently  Wassermann-negative.  They  are 
nevertheless  greatly  benefited  by  treatment  and  in  view  of  the  greatly 
increased  sensitiveness  of  the  present-day  Wassermann  test  it  is  an  open 
question  whether  or  not  much  importance  should  be  attached  to  the  per- 
sistence of  a  positive  Wassermann  reaction  in  old  well  treated  cases.  It  is 
not  possible  at  present  to  lay  down  any  general  rules.  Every  case  of  per- 
sistent Wassermann-positive  should  be  examined  by  spinal  puncture  to 
determine  the  possible  presence  of  asymptomatic  syphilis  of  the  central 
nervous  system. 

Syphilis  of  the  central  nervous  system,  especially  the  early  stages  of  tabes, 
always  demands  energetic  treatment.  In  addition  to  intravenous  injections 
of  arsphenamine  many  syphilographers  and  some  neurologists  advocate 
intraspinal  treatment.  The  treatment  devised  by  Swift  and  Ellis  and 
modified  by  Ogilvie  is  carried  out  as  follows : 

The  patient  receives  an  intravenous  injection  of  arsphenamine.  One 
hour  later  40  c.c.  to  50  c.c.  of  his  blood  is  drawn  aseptically  from  a  vein, 
the  blood  allowed  to  clot,  its  serum  separated  and  placed  on  ice  until 
next  day.  It  is  then  centrifuged,  one-quarter  to  one-half  milligram  of  ars- 
phenamine in  solution  added  and  the  serum  inactivated  at  56°  C.  for  forty 
minutes.  It  is  then  ready  for  use.  A  lumbar  puncture  is  made,  an  amount 
of  spinal  fluid  removed  equal  to  the  volume  of  serum,  12  c.c.  to  15  c.c,  it  is 
intended  to  inject,  then  15  to  20  c.c.  of  the  spinal  fluid  allowed  to  flow  into 
a  funnel-shaped  vessel  where  it  is  mixed  with  the  prepared  serum  and  the 
whole — the  spinal  fluid  plus  the  serum — is  made  to  flow  by  gravity  into  the 
subarachnoid  cavity.  The  patient  remains  recumbent  a  number  of  hours 
after  the  operation.  The  injections  are  repeated  at  two  weeks'  interval,  six 
to  eight  injections  constituting  a  course  and  two  courses  are  given  in  a  year. 
The  value  of  this  treatment  is  not  universally  admitted;  it  is  my  belief, 
however,  that  cases  of  tabes  in  which  destructive  lesions  are  not  far  advanced 
are  greatly  benefited  by  intraspinal  treatment,  symptoms  are  relieved  and 
the  disease  checked.  In  paresis  which  is  clinically  recognizable  little  or  no 
benefit  results  from  the  treatment.     An  early  serological  or  laboratory 


646  INFECTIOUS  DERMATOSES  DUE   TO  PROTOZOA 

diagnosis  of  paresis  has  never  more  than  a  certain  degree  of  probability. 
The  spinal  fluid  of  the  paretic  always  yields  a  "paretic  gold-sol  curve," 
together  with  pleocytosis,  albunhnosis  and  a  positive  Wassermann,  but 
similar  findings  are  observed  in  other,  non-paretic,  syphilitic  affections 
of  the  central  nervous  system  and  these  cases  do  well  under  treatment. 

In  pregnancy  the  problem  is  to  prevent  infection  of  the  fetus  by  keeping 
the  blood  of  the  mother  free  from  active  spirochetes.  Before  the  end  of  the 
third  month  of  pregnancy  when  placental  circulation  is  established,  energetic 
treatment  with  arsphenamine  and  with  moderate  doses  of  mercury  lest  the 
kidneys  be  injured  should  be  administered;  after  that  period  arsphenamine 
and  mercury  should  be  given  in  short  courses  with  short  periods  of  rest; 
one  injection  of  arsphenamine,  four  weeks  of  mercury  and  one  month  of 
rest.  In  pregnancy  in  the  asymptomatic  Wassermann-positive  syphilitic 
of  the  later  stages,  the  intervals  between  treatment  may  be  longer.] 

YAWS. 

Yaws — also  known  as  plan  and  framboBsia  tropica — is  a  contagious 
and  inoculable  disease  of  hot  countries,  which  manifests  itself  by 
crusted  papulo-  or  pustulo-vegetative  eruptions  and  is  caused  by 
a  spirochete. 

Yaws  is  endemic  and  widely  distributed  in  Indo-China,  certain 
parts  of  the  Indies,  the  Malaysian  Islands,  Oceanica,  equatorial 
Africa,  Central  and  Southern  America. 

After  an  incubation  period  lasting  from  fifteen  days  to  six  months, 
the  invasion  manifests  itself  by  general  symptoms,  a  slight  fever, 
digestive  disturbances,  headache,  bone  and  joint  pains  and  then  by 
a  furfuraceous  scaly  itching  eruption  (Fig.  185). 

In  other  cases  a  primary  sore  known  as  the  yaws-chancre  or  the 
yaws-matrix  develops  at  the  site  of  inoculation,  that  is,  most 
commonly  on  the  legs  or  in  the  face;  this  lesion  may  for  a  long  time 
remain  solitary  or  it  may  blend  with  a  generalized  eruption  of  the 
same  type.  This  so-called  chancre  really  has  the  same  objective 
features  as  the  lesions  which  follow  it  (p.  250),  frambesia  being  a 
monomorphous  disease.  Glandular  enlargement  is  inconstant.  The 
eruptions  spread  over  the  entire  integument,  lasting  several  months 
and  following  each  other  during  a  number  of  years.  The  mucous 
membranes  invariably  escape.  There  is  no  alopecia.  Visceral 
lesions  of  yaws  are  unknown. 

No  human  race  is  exempt  from  yaws.  The  disease  is  inoculable 
and  extremely  contagious,  even  indirectly,  but  it  is  not  venereal. 
It  is  usually  contracted  during  childhood,  favored  by  some  excoria- 
tion or  ulceration  which  serves  as  the  portal  of  entry  of  the  virus. 
Stinging  insects  may  contribute  to  its  dissemination.  It  is  not 
hereditary.  In  the  course  of  the  first  weeks  or  months,  auto-inocula- 
tion is  still  possible;  after  this  time,  a  relative  immunity  becomes 
established,  which,  however,  is  not  always  permanent. 

Analogies  and  a  possible  relationship  between  syphilis  and  yaws 


YAWS 


647 


have  Jong  been  noted,  but  there  are  considerable  differences:  syphilis 
is  universally  distributed,  is  not  auto-inoculable,  has  a  prescribed 
course  and  polymorphous,  non-pruritic  manifestations;  it  frequently 
involves  the  mucous  membranes  and  the  viscera;  moreover,  it  is 
hereditary. 

The  pathogenic  agent  of  yaws,  discovered  by  Castellani  in  1905, 
is  the  spirocheta  pertenuis  or  pallidula;  it  is  a  spiral  organism, 
morphologically  very  similar  to  the  treponema  of  syphilis.  Noguchi 
has  grown  it  in  cultures.  So  far  it  has  been  found  only  in  the  yaws- 
lesions  themselves,  but  not  in  the  blood  and  the  secretions.    Yaws 


Fig.  185.— Yaws.     Courtesy  of  Dr.  E.  B.  Vedder  (Knowles). 


is  inoculable  into  monkeys  and  even  into  rabbits.  It  does  not  confer 
immunity  against  syphilis  either  in  man  or  animals  and  syphilis 
on  the  other  hand  does  not  immunize  against  yaws.  But  the  extract 
of  yaws-papules  and  the  serum  of  human  beings  or  animals  having 
yaws  or  cured  of  the  disease,  yields  a  positive  Wassermann  reaction. 
The  former  modes  of  treatment  have  been  abandoned  since  the 
surprisingly  rapid  and  complete  action  of  the  arsenobenzols  has 
been  recognized.  Sometimes  one  intravenous  injection  proves 
sufficient.  One  month  after  the  introduction  of  this  remedy  the 
large  yaws-hospitals  in  Batavia  were  closed.    In  countries  where 


648 


INFECTIOUS   DERMATOSES  DUE   TO   PROTOZOA 


framboesia  tropica  prevails,  the  most  trifling  wounds  must  be  care- 
fully dressed  as  they  might   serve  as  an  entrance-portal   for  the 

infection. 

LEISHMANIOSES. 

Leishmania  (R.  Ross,  1903)  arc  protozoa  related  to  the  trypano- 
somes,  the  herpetomonas,  etc.;  they  assume  the  shape  of  oval  or 
pyriform  corpuscles,  from  '2  to  4^  in  length  by  H  to  3/*  in  width, 
containing  two  chromatic  masses  known  as  the  karyosome  and  the 
centrosome;  in  cultures  they  present  a  flagellate  stage.  They  are 
found  particularly  in  the  endothelia,  the  leukocytes,  the  connective 
tissue  and  in  macrophagic  cells  and  exceptionally  in  the  blood  of 
their  hosts. 


Fig.    186.— Orient! 


Oriental  Boil  (Furunculus  Orientalist.-  This  dermatosis,  which 
is  endemic  in  many  subtropical  or  tropical  regions  in  the  north  of 
Africa.  Eastern  Asia,  Central  and  South  America,  also  hears  the 
names,  according  to  the  different  countries,  of  Biskra  boil,  Aleppo 
boil,  Gafsa  boil,  Nile  boil  and  Delhi  boil;  Salek  or  one-year  boil  in 
Persia,  date-boil,  and  so  forth. 

It  is  characterized  by  pustular  and  ulcero-vegetative  lesions 
which  develop  without  impairment  of  the  genera]  health,  most 
commonly  in  the  fall  or  during  the  cool  season  of  the  year. 

After  an  incubation  of  ten  days  to  a  month,  sometimes  longer,  a 
red  spot  makes  its  appearance,  which  becomes  papular  and  pruritic, 
resembling  a  mosquito  bite;  next,  the  lesion  become  covered  with 
scales  or,  as  the  result  of  scratching  and  excoriat  ion,  with  crusts 
which  conceal  a  slowly  spreading  oozing  ulcer  with  a  wavy  outline 
(Fig.  186);  it  frequently  has  the  appearance  of  a  furuncle  or  crusted 


LEISHMANIOSES  649 

ecthyma  before  assuming  the  characteristic  features  of  its  adult  stage, 
which  have  been  described  elsewhere  in  this  book  (p.  250). 

The  lesions  are  preferably  situated  on  the  exposed  parts,  the  hands, 
the  face  and  the  limbs.  As  a  rule,  no  more  than  three  or  four  are 
present,  sometimes  only  one,  very  rarely  from  thirty  to  forty;  they 
develop  in  succession  and  are  therefore  of  different  ages.  The 
mucous  membranes  are  seldom  affected. 

Oriental  boil  is  inoculable  and  contagious;  it  confers  only  a 
temporary  immunity.  The  blood  yields  a  negative  Wassermann 
reaction. 

The  pathogenic  organism  discovered  by  J.  H.  Wright  (1903)  and 
named  by  him  helcosoma  tropicum  was  classified  by  Ii.  Ross  as 
leishmania  tropica  or  furunculosa.  It  is  very  closely  related  to, 
although  different  from,  leishmania  Donovani,  which  causes  kala- 
azar.  It  is  found  in  thin  sections  stained  with  carbolized  thionine, 
within  the  macrophage  cells  (Nattan-Larrier) ;  and  more  readily 
in  smear  preparations  treated  by  the  methods  of  Romanovski, 
Giemsa,  Laveran,  etc. 

It  was  successfully  grown  in  cultures,  in  a  flagellate  form,  by  Ch. 
Nicolle,  who  inoculated  it  into  the  macacus.  Dogs,  camels  and 
horses  are  said  to  offer  no  resistance  to  it.  Without  positive  proof, 
it  is  assumed  that  the  transmission  of  Oriental  boil  generally  takes 
place  through  the  intermediation  of  flies,  bugs,  mosquitoes  or  other 
stinging  insects,  especially  since  Nattan-Larrier  was  able  to  demon- 
strate the  presence  of  leishmanias  in  human  blood  in  the  vicinity  of 
the  lesions. 

The  treatment  consists  either  in  excision  of  the  lesions  or  in 
scraping  followed  by  cauterization  with  the  actual  cautery  or 
applications  of  potassium  permanganate  in  powder  form.  The 
efficacy  of  the  arsenobenzols  is  variously  estimated.  In  Brazil,  intra- 
venous injections  of  antimony  tartrate  are  advocated,  in  doses  of  0.05 
to  0.10,  in  sterilized  solutions  of  1  to  100  or  1  to  500  in  physiological 
salt  solution;  these  injections  actually  seem  to  be  very  efficacious. 
When  the  patient  leaves  the  countries  where  the  disease  is  endemic, 
cutaneous  leishmaniosis  tends  to  heal  spontaneously;  so  that  in 
temperate  zones  clean  dressings  may  be  considered  as  sufficient. 
The  cure  may  be  hastened  by  radiotherapy. 

Pian-Bois. — This  dermatosis  is  endemic  in  Guyana  among  foresters 
and  hunters.  Together  with  de  Christmas,  I  was  enabled  to  observe 
a  case  characterized  by  subcutaneous  nodules  opening  on  the 
skin  as  ulcers  with  a  granulating  floor;  the  lesions  were  situated 
on  the  back  of  the  hands  and  arranged  at  intervals  along  the  lym- 
phatics of  arm.  The  glands  become  indurated.  The  course  is  slow 
and  the  disease  may  recur.  Nattan-Larrier  (1909)  discovered  the 
pathogenic  agent  which  is  a  leishmania,  present  in  rather  scanty 


650  INFECTIOUS  DERMATOSES  DUE  TO  PROTOZOA 

numbers,  possessing  certain  special  features  and  named  by  him  the 
American  variety  of  Leishmania  tropica. 

Boubas  or  Framboesia  Brasiliana.  -The  disease  described  under 
this  name  by  Breda,  B.  Summer  and  others,  differs  from  yaws  in 
its  course  and  also  in  that  it  less  frequently  spares  the  buccal, 
pharyngeal,  laryngeal,  nasal,  conjunctival  mucous  membranes, 
etc.  The  initial  lesion  is  a  bulla  or  a  pustule,  which  is  followed  by 
a  superficial  slough;  next  appears  one  or  several  ulcero-prolifera- 
tive,  painless  and  non-pruritic  lesions  in  patches;  the  condition  may 
last  ten  or  fifteen  years  or  longer  and  cause  death  from  cachexia. 
Children  are  rarely  attacked  and  the  contagiousness  is  apparently 
slight. 

Boubas  were  attributed  by  Breda  to  a  bacillus  discovered  by  him 
in  the  lesions;  Fiocco  succeeded  in  growing  this  bacillus  in  cultures 
and  inoculating  it  into  rabbits.  However,  Splendore  and  Carini 
(1911)  have  shown  that  the  disease  represents  a  leishmaniosis. 

Espundia,  described  by  Escomel,  endemic  in  Peru,  Brazil  and 
other  parts  of  South  America,  begins  on  the  limbs  or  on  the  trunk 
with  a  nodule  which  opens  as  an  ulcer  with  a  granulating  floor, 
discharging  abundantly  and  not  particularly  painful;  ulcerative- 
granulating  and  destructive  bucco-naso-pharyngeal  lesions  next 
make  their  appearance;  the  duration  is  twenty  to  thirty  years. 
Buono  de  Miranda  and  Splendore  discovered  a  leishmania  which  is 
considered  by  Laveran  and  Xattan-Larrier  (1912)  as  belonging  to 
the  American  variety  of  Leishmania  tropica.  [According  to  Escomel 
(1919)  the  lesions  of  blastomycosis  are  sometimes  associated  with 
those  of  espundia  in  the  same  case.] 

Espundia,  Bouba,  perhaps  also  Pian-Bois,  are  therefore  probably 
identical  diseases,  namely  Leishmaniasis  Americana. 

Injections  of  tartar  emetic  are  recommended  as  in  the  treatment 
of  Oriental  boil;  arsenobenzol  is  useless. 


CHAPTER  XXX. 

DERMATOSES  OF  THE  LEUKEMIAS  AND   ANALOGOUS 
PATHOLOGICAL  CONDITIONS. 

CUTANEOUS  LEUKEMIAS. 

In  a  large  number  of  the  skin  diseases  which  have  been  previously 
discussed,  a  change  in  the  cellular  composition  of  the  blood  can  be 
demonstrated.  Not  to  mention  anemia  and  leukocytosis  which 
are  of  common  occurrence  in  many  infections  or  toxic  diseases  of  the 
skin  and  even  in  the  neurodermatoses,  it  suffices  to  point  out  that 
a  sometimes  very  considerable  eosinophilia  is  noted  in  pemphigus 
and  especially  in  Duhring's  disease,  where  the  local  eosinophilia  is 
still  more  marked;  in  cutaneous  hydrargyria,  likewise  with  local 
eosinophilia  (Hoffmann) ;  in  leprosy,  especially  the  tubercular  form ; 
it  has  finally  been  reported  in  some  cases  of  erythema,  urticaria, 
eczema,  etc.  However,  the  relations  between  these  eruptions  and 
the  modification  of  the  blood  are  neither  absolutely  constant  nor 
probably  direct. 

The  cutaneous  affections  to  be  dealt  with  in  this  chapter  are  on 
the  contrary  closely  related  to  organic  alterations  of  the  blood  or, 
more  accurately  speaking,  with  one  or  other  of  the  hyperplastic 
diseases  of  the  hematopoietic  organs  which  are  grouped  under  the 
heading  of  leukemias  and  analogous  pathological  conditions.  It  is 
therefore  indispensable  for  the  dermatologist  to  be  informed  on  the 
subject  of  these  general  diseases. 

Since  the  investigations  of  Ehrlich,  a  distinction  is  made  between 
two  fundamental  forms  of  leukemia:  (1)  The  lymphatic  leukemias 
in  which  the  hyperplasia  affects  the  glands  and  adenoid  structures 
of  the  same  kind,  tonsils,  closed  follicles  of  the  intestine,  thymus,  etc., 
including  also  the  spleen;  (2)  the  myeloid  leukemias  in  which  the 
lesions  affect  the  bone-marrow  and  the  myeloid  tissues,  among 
which  the  spleen,  as  an  organ  of  mixed  structure,  again  figures. 

These  hyperplasias  are  accompanied  by  the  passage  of  their  con- 
stituent cells  into  the  bloodstream,  sometimes  in  enormous  propor- 
tions, for  from  100,000  to  over  500,000  white  corpuscles  per  cubic 
millimeter  may  be  found  (true  leukemias).  In  other  cases,  this 
passage  takes  place  to  a  limited  degree  and  no  more  than  20,000  to 
30,000  white  corpuscles  are  found  in  the  blood,  or  even  a  normal 
number   (pseudo-leukemias,  subleukemias,   aleukemias) :  but  in  all 


652  DERMATOSES  OF  THE  LEUKEMIAS 

cases  the  customary  proportion  of  the  different  kinds  of  white 
corpuscles,  the  leukocyte  formula,  is  modified,  so  that  there  may  be 
for  example  a  relative  lymphocytosis  or  submyelemia;  all  degrees, 
subject  to  variations,  may  be  observed  in  the  same  case;  a  sub- 
leukemia  may  even  become  transformed  into  a  true  leukemia. 

The  leukemias  and  pseudoleukemias  are  chronic  diseases,  usually 
lasting  from  two  to  six  years  or  longer;  relatively  recent  observations 
have  shown  the  existence  of  a  rapid  form,  leading  to  death  in  a  few 
weeks  or  months  and  constituting  acute  leukemia. 

There  is  at  present  a  tendency  among  hematologists  to  group 
under  the  heading  of  lymphomatosis  all  the  hyperplastic  affections 
of  the  glandular  or  adenoid  system,  whether  leukemic  or  not,  chronic 
or  acute,  generalized  or  localized;  and  under  the  heading  of  myelo- 
matosis those  of  the  myeloid  system.  The  principal  forms  of  these 
are  outlined  in  the  following: 

Clinical  Forms.—  Chronic  lymphatic  leukemia  begins  insidiously 
with  fatigue,  emaciation,  hypertrophy  of  the  glands,  at  first  often 
with  a  submaxillary,  parotid  and  cervical  and  later  generalized 
localization,  almost  invariably  associated  with  an  enlarged  spleen 
and  sometimes  with  hypertrophy  of  the  liver.  The  white  corpuscles 
of  the  blood,  greatly  increased  in  number,  are  lymphocytes  in  a  pro- 
portion of  .10  to  95  per  100.  Histological  examination  of  the  glands 
and  other  hematopoietic  organs  shows  an  enormous  hyperplasia 
of  the  adenoid  tissue  (lymphadenia)  which  is  swollen  and  packed 
with  practically  pure  lymphocytes;  the  other  organs  and  viscera 
may  be  the  seat  either  of  leukemic  infiltration  or  of  true  lymph- 
adenomas. 

Aleukemic  lymphomatosis  (also  subleukemic  or  aleukemic  lymph- 
adenia, Trousseau's  adenia,  Hodgkin's  disease,  pseudoleukemia  of 
Cohnheim)  differs  from  the  above  only  by  the  subleukemic  or 
aleukemic  condition  of  the  blood.  Aside  from  its  progressive  and 
generalized  form,  there  exist  localized  forms  limited  to  certain 
groups  of  glands  (neck,  mediastinum,  abdomen,  etc.)  or  to  an  adenoid 
organ  (tonsil,  intestine),  which  may  develop  like  a  neoplasm  and  will 
be  referred  to  later. 

Chronic  myeloid  leukemia,  the  onset  of  which  is  very  obscure, 
manifests  itself  in  its  stationary  stage  by  an  enormous  spleen  with 
a  large  liver,  without  glandular  enlargement,  and  by  a  pale  com- 
plexion; the  blood  ordinarily  contains  about  300,000  white  corpuscles 
the  majority  of  which  are  granular  (polynuclears  and  myelocytes 
with  neutrophile  granules,  basophiles  and  eosinophil  ,  myeloblasts 
and  nucleated  rv(\  cells);  the  bone-marrow  is  gray  or  whitish  and  its 
constituents  are  actively  proliferating;  there  is  myeloid  transfor- 
mation of  the  spleen  and  accessorily  a  myeloid  infiltration  of  the 
lymphatic  system  and  the  liver;  there  may  be  myelomatosis  of  the 


CUTANEOUS  LEU  KE  MI  AS  653 

perivascular  tissue  in  the  entire  organism.  The  subleukemic  forms  of 
this  disease  (submyelemic  splenomegalies)  are  rare  and  still  a  subject 
of  controversy. 

Acute  leukemia,  which  occurs  in  a  not  easily  distinguishable 
lymphatic  form  and  a  myeloid  form,  behaves  like  an  acute  infection. 
The  onset  is  marked  by  chills,  splenic  pains,  general  fatigue  and  often 
by  angina  with  persistent  fever.  The  dominating  features  in  the 
clinical  picture  consist  in  the  following:  Sometimes,  moderate 
glandular  hypertrophies,  especially  at  the  neck,  reaching  the  tracheo- 
bronchial glands  with  mediastinal  symptoms  or  the  mesenteric 
glands  with  hypertrophy  of  the  spleen;  other  cases  are  associated 
with  hemorrhages,  epistaxis,  hematemesis,  melena,  etc.,  or  with 
buccopharyngeal  symptoms,  angina,  pseudoscorbutic  gingivitis; 
also  nervous  disturbances,  such  as  headache,  vertigo  and  asthenia. 
The  blood  contains  over  50,000  white  corpuscles,  which  have  reached 
an  imperfect  maturity,  large  lymphocytes  or  lymphoblasts,  or  very 
polymorphous  macrolymphocytes.  The  lesions  of  the  organs  are 
the  same  as  in  the  chronic  forms,  but  with  proliferation  and  infiltra- 
tion of  large  undifferentiated  lymphocytes. 

Aside  from  these  typical  forms  of  lymphomatosis  and  myeloma- 
tosis, atypical  forms  are  not  very  infrequently  encountered;  such  as: 

Regional  glandular  lymphadenoma,  without  leukemia,  not  easily 
differentiated  from  tuberculous  adenopathy; 

Lymphosarcoma  of  Kundrat-Paltauf,  which  presents  itself  as  a 
malignant  glandular  tumor,  at  first  regional,  with  a  tendency  to 
become  generalized,  invading  the  adjacent  organs  by  infiltration 
and  spreading  by  metastasis  {lymphosarcomatosis);  it  is  accompanied 
by  a  moderate  neutrophilia ; 

Chloroma  (or  green  cancer  of  Aran),  characterized  by  tumors  of 
the  cranial  periosteum  and  lymphomas  of  a  greenish  hue  in  all  the 
hematopoietic  organs,  with  lymphoid  or  myeloid  subleukemia; 

Lymphogranulomatosis  (of  Sternberg-Paltauf ) ,  a  progressive 
glandular  hypertrophy,  capable  like  lymphosarcoma  of  invasion 
and  production  of  metastases,  is  differentiated  from  aleukemic 
lymphomatosis  by  the  presence  of  yellowish  gray  points  in  cross- 
sections  and  by  a  mixed  lymphoid  and  myeloid  structure  analogous 
to  the  structure  of  wound-granulations,  hence  its  name  of  granuloma 
(Benda);  it  is  accompanied  by  a  moderate  leukocytosis.  This 
pathological  type,  which  has  not  been  extensively  studied  in  France, 
corresponds  according  to  Gravitz  and  others  to  the  majority  of 
cases  of  Cohnheim's  pseudoleukemia  and  Hodgkin's  disease.  Several 
authors  interpret  it  as  an  attenuated  tuberculosis,  a  genuine  glan- 
dular "tuberculide." 

Etiology  and  Character. — The  etiology  of  the  leukemias  and  dis- 
eases of  the  same  group  is  entirely  unknown. 


654  DERMATOSES  OF  THE  LEU KE Ml AS 

They  were  originally  supposed  to  be  of  neoplastic  character  and  the 
name  of"  cancer  of  the  blood"  (Bard)  was  actually  suggested  for  these 
cases.  As  a  matter  of  fact,  the  indefinite  cellular  proliferation  of 
certain  lymphomas  and  myelomas,  the  atypical  cell-forms  met  with 
in  certain  varieties,  the  invasion  of  the  vicinity  and  the  metastases, 
the  terminal  cachexia,  closely  simulate  the  malignant  tumors.  It  is 
undeniable  that  the  boundaries  between  lymphadenomas,  lympho- 
sarcomas and  sarcomas  arc  not  very  sharp  at  the  present  writing. 

On  the  other  hand,  a  large  array  of  facts,  notably  the  existence 
of  acute  febrile  forms  of  the  leukemias  is  in  favor  of  their  infectious 
character.  There  is  in  all  probability  no  reason  to  look  for  a 
"microbe  of  the  leukocythemias"  and  isolated  findings  along  this 
line  of  inquiry  have  not  been  confirmed.  Cultures  and  inoculations 
into  animals  are  generally  unsuccessful;  in  a  well-marked  case  of 
acute  leukemia,  I  carried  out  inoculations  of  blood  and  tissue-parts 
into  two  monkeys  without  result.  But  the  frequency  in  the  patient's 
antecedents  of  various  infectious  diseases,  eruptive  fevers,  anginas, 
especially  of  syphilis  and  tuberculosis,  as  well  as  the  analogy  in  the 
course  of  certain  lymphomatoses  and  lymphogranulomatoses  with 
the  tuberculous  adenopathies  are  suggestive  of  a  less  simple  inter- 
pretation. Possibly,  various  attenuated  infections  or  those  which 
develop  on  an  allergic  soil,  excite  a  reaction  which  after  being  at 
first  defensive,  reconstructive  and  hyperplastic,  ultimately  becomes 
atypical,  destructive  and  offensive  for  tissues  of  the  same  kind  or 
those  which  have  been  invaded  in  the  vicinity  or  at  a  distance;  the 
process,  inflammatory  at  the  onset,  might  in  this  way  acquire  the 
attributes  of  a  malignant  neoplasm. 

Cutaneous  Manifestations. — These  may  be  observed  in  all  the 
forms,  chiefly  in  the  subleukemic  or  aleukemic  lymphomatoses 
(pseudoleukemias),  in  chronic  lymphatic  leukemia,  in  the  acute 
leukemias,  in  the  case  of  lymphosarcoma,  lymphogranulomatosis, 
etc. ;  they  are  less  common  in  chronic  myeloid  leukemia,  but  never- 
theless undeniable  (Brunsgaard,  Lian).  They  do  not  differ  among 
themselves  according  to  the  type  of  disease  in  which  they  occur;  in 
the  very  noteworthy  and  learned  contribution  of  Xanta  to  the  study 
of  the  lymphodermas  and  myelodermas  (Annales  de  Dermatologie, 
1912),  this  author  agrees  with  his  predecessors  in  stating  that  the 
blood-formula  has  no  bearing  on  the  aspect  of  the  cutaneous  lesions. 

Besides  being  extremely  variable  and  multiple,  these  cutaneous 
manifestations  are  often  polymorphous  in  the  same  case.  They  may 
be  persistent  or  transitory,  delayed  or  premature,  sometimes  pre- 
ceding the  glandular  or  splenic  enlargement  and  the  changes  in  the 
blood. 

From  an  objective  point  of  view,  they  may  be  divided  into  three 
groups: 


PLATE   III 


/ 


. 


Leukemic  Tumors  of  the  Cheek,  Nose  and   Lobule   of  the  Ear, 
in  a  Case  of  Leukemic  Lymphomatosis. 


CUTANEOUS  LEUKEMIAS  655 

1.  Some  are  of  very  dissimilar  and  rather  ordinary  appearance; 
representing  the  leukemides  of  Audry  and  his  pupil  Germer  (These, 
1902).  They  consist  either  of  persistent  pruritus  with  dryness  of 
the  skin;  or  of  pruriginous  exanthemas  in  the  form  of  urticaria, 
sometimes  of  papular  or  vesicular  urticaria,  simulating  polymor- 
phous erythema  or  Duhring's  disease;  or  the  lymphadenic  prurigo 
of  Dubreuilh  (p.  495)  which  is  accompanied  by  papules  and  licheni- 
fication.  Patches  of  eczematization  also  occur,  probably  due  to 
scratching,  as  well  as  pyodermatitides  through  superadded  infec- 
tion, leaving  pigmented  macules  and  small  cicatrices.  Finally,  there 
may  be  eruptions  of  purpura  with  easily  provoked  hemorrhages.  His- 
tology has  only  rarely  been  able  to  demonstrate  miliary  lymphomas 
in  certain  leukemides,  such  as  prurigo  papules. 

2.  Leukemic  erythrodermas  have  been  described  which  do  not  seem 
to  constitute  a  generic  type.  Some  cases  are  perhaps  generalized 
eczemas;  others  are  premycotic  erythrodermas  (p.  119) ;  finally,  some 
(Nicolau,  Annates  de  Dermatologie,  1904)  present  themselves  under 
the  aspect  of  generalized  exfoliative  dermatitis  or  of  pityriasis  rubra 
with  relative  lymphocytosis.  In  this  connection  the  famous  case  of 
Kaposi  (1885),  entitled  lymphodermiaperniciosa. is  invariably  quoted; 
this  was  characterized  by  moist  and  scaly  redness,  pruritus,  a  doughy 
thickening  of  the  skin,  followed  by  cutaneous  and  subcutaneous 
nodosities  which  became  ulcerated;  hypertrophy  of  the  glands  and 
of  the  spleen,  genuine  leukemia,  developed  rapidly  and  the  patient 
promptly  died;  the  case  was  probably  one  of  mycosis  fungoides, 
beginning  with  erythroderma  and  terminating  as  lymphatic  leukemia 

3.  Leukemic  tumors  and  infiltrations  are  more  characteristic. 
There  exists  a  localized  clinical  form,  situated  anywhere,  but  often 
on  the  face;  in  these  cases,  flabby  and  painless,  purplish  or  brownish- 
red  tumors,  with  a  thin  smooth  skin,  traversed  by  telangiectases, 
are  seen  to  develop  on  the  cheeks,  the  nose  and  the  ears;  the  swel- 
lings slowly  increase  in  size,  without  a  marked  tendency  to  necrosis 
and  ulceration.  I  have  had  occasion  to  follow  a  case  during  fifteen 
years  (Plate  III).  They  may  be  found  on  the  mucous  membranes. 
Sometimes,  the  condition  consists  rather  of  diffuse  purplish  infil- 
trations in  which  vitropressure  shows  translucid  miliary  nodules. 

Another  form  presents  small  red,  bluish  or  dusky  tumors,  some- 
times resembling  lepromata.  In  a  case  of  acute  leukemia  in  a  child 
of  thirteen  years,  I  noted  very  numerous  nummular  lilac  patches, 
marking  the  site  of  not  very  prominent  dermo-hypodermic  nodosities 
distributed  over  the  thorax,  abdomen,  forehead  and  scalp. 

The  structure  of  these  newformations  is  that  of  lymphomata 
or  lymphadenomata;  small  or  medium-sized  lymphocytes  (lympho- 
blasts  or  macrolymphocytes)  fill  the  meshes  of  a  fine  adenoid  network 
which  is  supported  by  the  vascular  walls. 


656  DERMATOSES  OF   THE  LEUKEMIAS 

In  other  cases,  which  seem  to  me  relatively  less  uncommon,  there 
exist  multiple   cutaneous  tumors,  some  of  which   are   voluminous 

and  occasionally  undergo  necrosis  and  ulceration;  their  structure 
comprises  cells  of  various  types,  a  considerable  number  having  the 
characteristics  of  the  constituents  of  lymphomata  or  myelomata, 
although  more  or  less  modified  and  atypical;  these  cells  are  enclosed 
in  a  network  with  strands  of  variable  thickness,  fairly  large  in  places 
and  provided  with  connective-tissue  cells.  These  are  cases  of 
lymphosarcoma  and  lymphosarcomatosis,  whose  relations  with  the 
leukemias  are  doubtful  and  which  closely  approximate  the  sarcomas. 

Diagnosis.  In  a  general  way  it  may  be  stated  that  whenever  the 
physician  finds  himself  confronted  with  a  cutaneous  manifestation 
which  may  be  a  leukemide,  a  leukemic  erythroderma,  or  a  lympho- 
matous  or  myelomatous  tumor,  he  should  keep  in  mind  the  leukemic 
and  pseudoleukemic  states  and  look  for  their  symptoms. 

In  the  presence  of  a  coexisting  progressive  glandular  hypertrophy 
or  splenic  hypertrophy,  with  corresponding  general  phenomena  and 
the  characteristic  lesion  of  the  blood,  all  doubts  are  removed. 

When  no  such  coexistence  is  found  at  the  time  of  the  first  exami- 
nation, it  is  advisable  not  to  discard  too  hastily  the  idea  of  a  possible 
relation  between  the  skin  affection  and  an  as  yet  undeveloped 
leukemic  state,  but  this  should  on  the  contrary  be  looked  for  very 
carefully  [by  repeated  examinations  of  the  blood  at  intervals  of  one 
or  two  weeks]. 

This  rule  is  especially  imperative  in  case  of  tumors  of  ambiguous 
character  which  may  be  leukemic,  lymphosarcomatous  or  sarcoma- 
tous. Laboratory  procedures  should  be  called  upon  to  assist  the 
clinical  examination;  in  addition  to  careful  control  of  the  hemato- 
poietic organs  by  repeated  serial  hematological  examinations,  recourse 
must  be  had  to  biopsy,  either  of  carefully  selected  eruptive  lesions 
or  of  tumor  fragments  and  possibly  of  a  lymph  gland.  Fixing  agents 
and  stains  applicable  to  the  cytological  examination  of  the  constitu- 
ents, notably  those  of  the  myeloid  series,  must  be  employed. 

In  attempting  to  decide  between  the  diagnosis  of  a  lymphoma  or 
a  sarcoma,  for  example,  the  following  considerations  must  not  be 
losl  sight  of:  the  criterion  of  the  "adenoid  plexus"  is  by  no  means 
entirely  conclusive;  it  is  not  always  possible  to  distinguish  the  cells 
derived  from  the  blood  (hematogenous)  from  the  cells  originating 
locally  in  the  tissues  (histogenetic) ;  although  it  is  true  in  a  general 
way  that  the  constituents  of  lymphomata  are  merely  infiltrated 
into  preexisting  tissues  whereas  those  of  sarcomata  replace  the 
latter,  this  is  not  a  reliable  feature  since  the  leukemic  constituents 
are  known  to  possess  the  power  of  local  multiplication  through 
karyokinesis;  one  may  go  so  far  as  to  admit,  with  Dominici  and 
others,  the  possibility  of  a  primary  development  of  lymphoma  in  the 


MYCOSIS  FUNGOIDES  G57 

skin,  as  a  mesenchymatous  tissue,  more  particularly  around  its 
vessels,  through  a  revival  of  its  fetal  hematopoietic  properties. 

It  is  only  at  the  expense  of  persevering  investigations  along  this 
line  that  we  may  hope  to  encounter  favorable  cases  permitting  a 
better  understanding  of  the  cutaneous  lymphomata  and  myelomata 
as  well  as  their  relations  with  the  malignant  connective-tissue 
tumors  or  sarcomata. 

MYCOSIS  FUNGOIDES.1 

Mycosis  fungoides  was  first  separated  and  named  by  Alibert  and 
accurately  described  by  Bazin;  it  is  also  known  as  cutaneous 
lymphadenia  of  Ranvier,  Gillot  and  Demange  and  as  granuloma 
fungoides  of  Auspitz.  It  is  a  chronic  general  disease,  taking  an 
irregular  course,  almost  invariably  fatal,  relatively  rare  and  of 
unknown  nature. 

Symptoms. — Mycosis  fungoides  manifests  itself  by  very  diverse 
eruptions  and  special  tumors  of  an  always  identical  structure. 

The  onset,  which  is  extremely  insidious,  may  take  place  in  four 
different  ways:  (1)  as  a  generalized  and  prolonged  pruritus,  with 
nothing  to  account  for  it  in  the  beginning;  (2)  as  polymorphous 
premycotic  eruptions,  to  be  described  presently;  (3)  as  a  premycotic 
erythroderma  (p.  119);  (4)  as  primary  tumors. 

The  polymorphous  'premycotic  eruptions  are  transitory  or  per- 
sistent; they  assume  the  form  of  erythematous,  roseolar,  urticarial, 
circinate  or  erysipeloid  spots  or  patches;  of  eczematizations  prob- 
ably due  to  scratching;  more  rarely,  of  purpura,  crops  of  vesicles 
or  bullae,  or  of  pyodermatitides.  Sometimes  there  are  more  station- 
ary infiltrated  patches  known  as  eczemato-lichenous  patches,  with 
irregular  outlines,  continuous  or  interwoven,  slightly  prominent,  of 
a  yellowish  or  purplish  red  color,  which  are  the  seat  of  severe  itching. 
This  surface  may  be  scaly,  oozing  or  crusted;  or  again,  which  is 
more  significant,  it  may  be  criss-crossed  as  in  lichenization.  The 
number,  the  distribution  and  the  duration  of  these  premycotic 
eruptions  are  too  variable  to  permit  of  a  description. 

In  the  developed  stage,  the  usual  findings  are  as  follows:  (1) 
Extensive  eczematiform  and  lichenized  surfaces,  with  edema  of  the 
skin,  diffusely  covering  the  face  which  thereby  acquires  a  fairly 
characteristic  leontiastic  appearance;  nearly  the  entire  integument 
may  be  involved,  although  islands  of  healthy  skin  are  almost 
invariably  demonstrable;    (2)  infiltrated  patches,   of  a  brick  red 

1  In  the  first  edition  of  this  book,  this  disease  is  discussed  under  the  infectious 
dermatoses;  this  classification,  although  based  upon  undeniable  analogies,  was  not 
supported  by  proof.    I  now  classify  it  with  the  cutaneous  leukemias,  with  which  it 
definite  affinities, 
42 


658 


DERMATOSES  OF  THE  LEUKEMIAS 


color,  of  variable  extent,  with  an  orange-peel  or  mammillated  sur- 
face; (3)  mycotic  tumors  (Fig.  187). 

The  latter,  at  their  onset  of  the  size  of  a  cherry  to  that  of  half  a 
mandarin  orange,  originate  on  one  of  the  preceding  lesions  or  some- 
times in  healthy  skin;  they  are  more  or  less  soft,  of  a  dark  red  color, 
hemispherical,  not  infrequently  constricted  at  their  base,  umbili- 
cated  and  indented,  so  that  they  have  been  compared  to  a  tomato; 
they  may,  however,  assume  a  semicircular,  crescentic  or  polycyclic 
form.  They  often  become  ulcerated,  through  superficial  erosion  or 
through  central  necrosis,  while  spreading  peripherally. 


Fig.  187.- 


-Mycosis  fungoides.     Extensive  eczemato-lichenous  patches  of  the  back, 
with  partially  ulcerated  mycotic  tumor. 


There  result  enormous  ulcerated  tumors  which  may  become 
conglomerated  and  attain  the  size  of  an  adult's  head,  or  large  ulcers 
with  a  ragged,  sanious,  gangrenous  floor,  bordered  by  a  fungoid 
elevation. 

It  is  a  remarkable  fact  that  these  tumors  may  at  any  stage  become 
absorbed  and  disappear  spontaneously,  leaving  no  trace,  or  being 
followed  merely  by  a  soft  white  cicatrix  with  a  pigmented  areola; 
other  tumors  then  form  in  proportion  at  different  points  of  the  body. 

They  are  situated  especially  on  the  trunk,  the  face  and  on  the 
first  segments  of  the  limbs, 


MYCOSIS  FUNGOIDES  659 

The  glands  are  sometimes  enlarged  early  in  the  disease.  From 
the  start  any  preexisting  nevi  become  swollen  simulating  incipient 
tumors.    Alopecia  of  the  affected  regions  is  the  rule. 

The  course  extends  over  a  period  of  from  two  to  twenty  years, 
interrupted  by  spontaneous  remissions  which  may  simulate  a  cure. 
The  patient's  strength,  complexion,  weight  and  digestive  functions 
finally  become  impaired  and  death  occurs  in  marasmus  or  as  the 
result  of  a  complication. 

In  the  form  with  primary  tumors  (a  tumeurs  d'emblee),  described 
by  Vidal  and  Brocq,  the  tumors  are  discrete  and  restricted  to  one 
region  of  the  body,  originating  in  healthy  skin  or  on  non-pruritic 
patches,  without  swelling  of  the  glands ;  they  may  become  absorbed 
without  ulceration.  This  type  is  very  closely  related  to  the  sarco- 
mata according  to  Brocq;  it  also  approximates  the  leukemic 
tumors. 

Pathological  Anatomy. — In  a  contribution  of  mine  to  the  study  of 
the  premycotic  eruptions  (1910),  I  showed  that  those  which  are 
clinically  of  ordinary  appearance,  for  example  eczematous  or  lichen- 
oid, have  nothing  unusual  in  their  histology;  the  demonstrable 
changes  of  acanthosis,  papillomatosis,  spongiosis,  exocytosis  and 
partial  parakeratosis  are  those  of  eczematization  due  to  scratching. 
A  biopsy  at  this  stage  of  the  disease  would  therefore  not  help  the 
diagnosis. 

Premycotic  erythroderma,  on  the  contrary,  has  a  characteristic 
structure  (Fig.  29) ;  namely,  that  of  the  mycotic  tumors,  but  spread 
out  as  a  thin  layer  in  the  papillary  body;  often  the  intra-epidermic 
cellular  nests  which  are  peculiar  to  mycosis  are  demonstrable, 
differing  through  their  sharp  boundaries  from  the  small  islands  of 
spongiosis  seen  in  eczema. 

The  mycotic  tumors  are  uniformly  composed  of  a  tissue  of  lympho- 
matous  appearance,  which  led  the  first  observers  (Ranvier,  Gillot, 
etc.)  to  the  assumption  of  a  "cutaneous  lymphadenia."  A  fine 
adenoid  network,  its  strands  resting  upon  the  vascular  walls,  is 
packed  with  a  variety  of  cells.  The  great  majority  of  these — 
rounded  or  polygonal,  approximately  the  size  of  a  polynuclear  cell, 
with  a  round  or  variably  deformed  nucleus,  with  more  abundant 
protoplasm  than  that  of  a  lymphocyte,  sometimes  containing  baso- 
philic granules — seem  to  be  atypical  myelocytes  of  lymphoblastic 
origin.  Furthermore,  there  are  found,  in  variable  proportions, 
connective-tissue  cells,  small  lymphocytes,  large  mononuclears, 
sometimes  chorioplasts  or  giant  cells,  plasmocytes  and  mast-cells. 
Pautrier  and  Fage  in  an  interesting  case  encountered  a  large  number 
of  eosinophiles  and  mast-leukocytes,  apparently  formed  locally  at 
the  expense  of  the  lymphocytes.  In  a  general  way,  there  is  marked 
predominance  of  a  certain  variety  of  lymphoid  cells,  with  distinct 


660  DERMATOSES  OF  THE  LEU  KE  MI  AS 

polymorphism    of    the    other    constituents.      Many    karyokinetic 

figures  are  found. 

The  epidermis  of  the  tumors  is  hyperacanthotic  at  their  borders, 
eroded  or  missing  in  ulcerated  eases.  Sometimes  large  numbers  of 
"cell  nests"  (Fig.  29,  a)  are  found,  filled  with  lymphoid  eells. 

The  composition  of  the  blood  is  not  uniform  in  all  eases  and  varies 
in  the  course  of  evolution  of  a  given  ease.  A  certain  degree  of 
anemia  and  eosinophilia  is  rather  common;  neutrophile  poly- 
nucleosis is  not  rare;  sometimes,  a  slight  myeloid  reaction  has  been 
noted.  The  leukemia  or  leukocytosis  which  have  repeatedly  been 
demonstrated  in  the  terminal  stage,  is  difficult  of  interpretation. 

Nothing  very  definite  is  known  concerning  the  character  of  the 
visceral  lesions  which  have  been  found  rather  frequently  in  the 
lungs,  the  kidneys,  the  suprarenals  and  more  rarely  in  the  serous 
membranes,  the  bone-marrow  and  the  liver  of  mycotic  patients; 
Brandweiner  found  metastatic  tumors  in  the  brain,  with  the  same 
structure  as  those  of  the  skin.  This  matter  requires  further  investi- 
gation. 

Etiology  and  Character. — Mycosis  fungoides  is  known  to  be  neither 
hereditary  nor  contagious.  It  is  encountered  somewhat  more 
frequently  in  men  than  in  women,  especially  between  the  age  of 
thirty  and  fifty  years.  [In  the  American  Dermatological  Associa- 
tion's statistics  it  occurred  once  in  about  3000  cases  of  all  skin 
diseases.] 

The  etiology  and  character  of  the  disease  are  still  problematical. 
A  large  array  of  arguments  is  in  favor  of  its  infectious  character, 
although  no  parasitological  or  experimental  proof  has  so  far  been 
furnished.  To  admit  its  sarcomatous  character,  with  Kaposi, 
means  to  strain  the  analogies  and  to  content  oneself  with  a  word. 
While  it  is  no  longer  possible  to  maintain  that  mycosis  fungoides 
is  merely  the  cutaneous  form  of  lymphadenia,  it  must  be  recognized 
that  it  is  nevertheless  most  closely  related  to  the  lymphodermas, 
myelodermas  and  especially  the  lymphogranulomatoses  which  are 
infectious  neoplasms.  It  is  especially  important  to  keep  in  mind 
cases  which  are  known  to  have  terminated  in  leukemia.  Some  day 
it  ma}'  be  discovered  that  mycosis  fungoides  is  based  upon  a  reaction 
of  the  lymphoid  or  myeloid  apparatus,  under  the  influence  of  still 
unknown  or  variable  pathogenetic  agents. 

Diagnosis. — At  the  onset  a  diagnosis  may  be  impossible.  The 
persistence  of  polymorphous  erythematous,  eczematous,  lichenoid 
eruptions  or  of  erythroderma,  especially  when  presenting  the  feature 
of  the  edematous  infiltration  which  I  have  emphasized  and  when 
associated  with  severe  itching,  should  arouse  a  suspicion  of  pre- 
mycotic  manifestations.  In  such  cases,  biopsy  is  necessary,  but  I 
have  already  pointed  out  that  the  histological  lesions  are  often  com- 


MYCOSIS  FVNGOIDES  CGI 

monplace  and  possess  diagnostic  value  only  in  so  far  as  they  approach 
those  of  premycotic  erythroderma. 

In  the  stage  of  infiltrated  patches  and  tumors,  the  clinical  picture 
is  very  characteristic;  but  before  making  a  diagnosis  of  such 
serious  import,  it  should  be  confirmed  by  histological  examination 
and  blood-analysis.  The  sero-diagnostic  method  of  complement- 
fixation  with  an  extract  of  mycotic  tumors  serving  as  the  antigen, 
proposed  by  Gaucher,  Brin  and  Joltrain,  has  yielded  encouraging 
but  still  unreliable  results. 

Treatment  of  Mycosis  Fungoides  and  Cutaneous  Leukemias. — The 
periods  of  spontaneous  improvement  which  are  apt  to  interrupt  the 
clinical  course  of  mycosis  and  the  chronic  leukemias  make  it  difficult 
to  estimate  the  efficacy  of  the  treatment  instituted.  It  is  reasonable 
and  entirely  indicated  to  treat  the  premycotic  eruptions,  the  erythro- 
dermas and  the  more  or  less  ordinary  leukemides  locally,  according 
to  their  eczematous  or  pruriginous  appearance,  etc.,  like  the  analo- 
gous skin  affections,  often  with  real  benefit  to  the  patient. 

Ulcerated  tumors  should  be  cleansed,  dressed  aseptically,  tam- 
poned with  camphorated  naphthol,  etc.  Sometimes  the  absorption 
of  tumors  and  infiltrations  has  been  brought  about  by  means  of 
topical  applications  of  pyrogallol,  the  employment  of  which  neces- 
sitates careful  control  of  the  urine;  or  other  reducing  agents  may 
be  used.  Surgical  removal  cannot  be  recommended.  Mercurial 
injections  have  seemed  to  me  to  exert  a  favorable  influence  in  a  few 
cases  of  premycosis. 

The  fundamental  methods  of  treatment,  however,  superior  to  all 
others,  are  represented  by  arsenic  and  by  radiotherapy.  The  classi- 
cal employment  of  arsenic  by  the  mouth  or  by  intramuscular  injec- 
tions in  progressive  doses,  is  at  present  replaced  by  intravenous 
injections  of  novarsenobenzol;  the  effect  may  seem  to  be  favorable, 
but  is  more  apt  to  be  doubtful  or  negative. 

[In  these  chronic  disorders,  the  effect  of  arsenic  is  developed 
only  when  the  drug  is  administered  in  full  doses  and  over  a  long 
period  of  time.  The  arsenobenzols  exercise  their  specific  effect  in 
syphilis  not  qua  arsenic  but  because  of  a  peculiar  molecular  struc- 
ture which  renders  them  spirocheticidal.  They  are  of  value  there- 
fore only  in  the  spirochetal  infections.  Their  action  is  necessarily 
too  evanescent  to  be  of  use  when  the  metabolic  effect  of  arsenic  is 
the  object  of  its  administration.  I  have  found  arsenic  by  daily 
hypodermatic  injections  in  courses  of  a  month  to  be  of  decided  value 
in  the  leukemias,  not  only  in  controlling  the  early  eruptions  but  also 
in  favorably  modifying  the  blood-picture.  I  use  the  formula  1$  sodii 
arsenatis,  phenolis,  aa  2.0,  aquse  100.0.  Beginning  with  0.5  c.c, 
the  daily  dose  is  gradually  increased  until  it  reaches  2.0  or  3.0  c.c. 
at  which  point  it  remains  stationary  for  a  week,  thence  declining 


662  DERMATOSES  OF  THE  LEUKEMIAS 

rapidly.    The  course  lasts  about  a  month  and  may  be  repeated  after 
a  two  months'  interval.    The  injections  are  absolutely  painless.] 

On  the  other  hand,  it  is  unanimously  conceded  that  radiotherapy 
is  the  treatment  of  choice  in  all  the  diseases  of  this  group.  In 
different  cases  the  glandular  masses,  the  spleen,  the  bones,  or  again 
the  tumors  or  the  various  cutaneous  lesions  are  exposed  to  the  rays, 
with  or  without  filter,  in  carefully  regulated  doses,  using  caution 
and  judgment.  The  rapidity  with  which  the  hyperplasias  are 
reduced  and  the  tumors  or  infiltrations  made  to  disappear,  while 
the  leukocyte  formula  of  the  blood  becomes  modified  is  very  remark- 
able and  has  encouraged  great  expectations.  It  may  be  stated  that 
although  a  noteworthy  improvement  and  sometimes  more  or  less 
lasting  apparent  cures  are  thus  obtained,  no  certain  and  definite 
cures  have  as  yet  been  reported. 


CHAPTER  XXXI. 
TUMORS  OF  THE  SKIN. 

Tumors  or  neoplasms  are  circumscribed,  non-inflammatory  new- 
formations  having  a  tendency  to  persist  and  increase  in  size,  of 
unknown  etiology. 

The  group  of  tumors  was  formerly  more  comprehensive  than  it  is 
at  the  present  day,  for  originally  all  swellings  were  grouped  under 
this  heading;  for  a  very  long  time,  until  the  discovery  of  their 
infectious  character,  the  tuberculomas,  syphilomas,  lepromas,  acti- 
nomycosis and  so  forth,  ranked  as  tumors.  In  a  general  way, 
this  is  a  provisional  group;  as  soon  as  a  neoplasm  has  surrendered 
the  secret  of  its  origin,  it  ceases  to  be  considered  as  a  tumor  and 
is  aligned  with  the  infectious  or  other  diseases;  for  this  reason  I 
regard  as  justified  the  introduction  of  the  words  "of  unknown 
etiology"  into  the  terms  of  the  definition  of  neoplasms. 

In  a  certain  number  of  tumors,  although  their  first  cause  still 
escapes  us,  the  pathogenic  mechanism  to  which  they  are  referable 
can  nevertheless  be  suspected.  As  a  matter  of  fact,  there  are  alto- 
gether only  three  conceivable  mechanisms  capable  of  giving  rise  to 
pathological  neoplasms.  These  must  necessarily  be  due  to:  either 
an  original  malformation;  or  to  a  reaction  of  the  tissues  against 
external  injurious  agents,  a  reaction  which  is  described  as  inflam- 
matory; or  finally  to  the  deposit  or  retention  of  elaborated  or 
secreted  autochthonous  substances. 

Among  the  tumors  of  the  skin,  a  considerable  number  belong  to 
the  first  group,  namely  the  nevi. 

Others  are  almost  certainly,  in  spite  of  the  terms  of  the  above 
definition,  of  inflammatory  or  infectious  character,  as  results  from 
their  contagiousness  or  from  their  structure;  such  are  the  warts, 
molluscum  contagiosum,  perhaps  certain  sarcomas,  etc. 

As  retention  tumors  may  be  cited  the  sebaceous  cysts,  the 
xanthomas,  the  tophi  of  gout;  and  perhaps  urticaria  pigmentosa. 

As  to  the  majority  of  neoplasms,  however,  for  example,  epithelial 
cancers,  their  origin  remains  as  yet  inexplicable.  Furthermore,  it 
must  be  kept  in  mind  that  in  the  ultimate  analysis  the  three  processes 
are  perhaps  neither  irreducible  nor  incompatible.  It  has  actually 
been  shown  that  imperceptible  transitions  occur  between  the 
inflammatory  hyperplasias,  the  nevus-like  malformations  and  the 
retention-tumors. 


064  TUMORS  OF  THE  SKIN 

On  the  other  hand  from  the  point  of  view  of  their  clinical  behavior, 
although  sonic  tumors  arc  benign,  behaving  simply  like  an  acquired 
and  persistent  local  deformity,  and  others  are  malignant,  destructive, 
invasive  and  subject  to  dissemination  by  metastasis,  all  intermediate 
degrees  between  these  two  courses  are  met  with,  as  well  as  transi- 
tions from  one   form   into  the  other. 

On  the  whole,  although  it  comprises  extremely  dissimilar  affec- 
tions, this  nosographical  group  of  tumors  must  still  be  provisionally 
maintained  for  the  time  being. 

Several  classifications,  clinical,  anatomical,  pathogenic,  have  been 
suggested  and  can  be  combined  to  a  certain  extent.  I  shall  therefore 
subdivide  this  class  into  three  orders: 

1 .  Nevi,  the  nevic  tumors  really  belong  anatomically  to  one  of  the 
two  following  groups;  but,  it  seems  to  me  desirable  to  present  a 
general  survey  of  these  malformations,  whether  they  constitute 
neoplasms  or  not. 

'2.    Epithelial  tumors. 

3.  Connective-  and  Vascular-tissue  tumors. 


NEVI. 

Nevi — popularly  designated  under  the  names  of  birthmarks, 
portwine  stains,  liver  spots,  beauty  spots,  etc. -are  congenital  mal- 
formations of  the  skin,  assuming  the  form  of  persistent  spots  or, 
tumors.     Such  is  their  classical  definition. 

It  has  long  been  known,  however,  that  these  deformities  are  by 
no  means  strictly  congenital  and  unchangeable.  Many  nevi  spread, 
enlarge  or  diminish  in  size.  Some  do  not  appear  until  after  birth, 
at  the  time  of  puberty  or  even  later.  Nor  is  there  any  valid  reason 
why  the  name  of  nevi  should  not  be  applied  to  certain  entirely 
analogous  spots  or  outgrowths  which  do  not  develop  until  adult 
life  or  in  old  age. 

Nevi  would  therefore  be  more  accurately  defined  as  circum- 
scribed deformities  of  the  skin,  of  embryonic  or  developmental 
origin,  appearing  at  any  age  and  taking  a  very  slow  course. 

The  view  according  to  which  nevi  are  dependent  upon  emotional 
or  physical  disturbances  experienced  by  the  mother  during  preg- 
nancy, rests  on  no  solid  basis. 

Nevi  arc  of  enormous  frequency.  Individuals  entirely  free  from 
them  are  exceptional.  The  hereditary  character  of  a  predisposition 
for  nevi  is  very  obvious  and  in  certain  families  they  arc  remarkably 
abundant. 

Numerous  or  large  nevi  are  not  infrequently  met  Avith  in  erratic 
or  feeble-minded  persons  and  idiots,  so  that  they  have  been  desig- 
nated by  some  as  a  hallmark  of  degeneration,  an  obviously  exag- 
gerated statement. 


MevI  665 

It  must  be  understood  that  in  some  cases  it  is  not  a  question  of 
solitary  and  as  it  were  accidental  products,  but  of  profuse  sometimes 
regional  or  systematized  eruptions  of  nevi  of  various  types,  asso- 
ciated Math  other  malformations:  Recklinghausen's  disease,  lenti- 
ginosis, perhaps  xeroderma  pigmentosum,  etc.,  to  which  this  remark 
is  applicable,  may  be  considered  as  nevic  diseases. 

Four  forms  of  nevi  are  recognized:  (1)  Pigmentary  nevi;  (2) 
tuberous  non-vascular  nevi;  (3)  adenomatous  nevi,  in  which  some 
of  the  cysts  may  be  included;  these  will  be  discussed  with  the 
epithelial  tumors;  (4)  vascular  nevi,  which  will  be  found  under  the 
heading  of  angiomas. 

1.  Pigmentary  Nevi. — These  are  brown  or  blackish  spots,  without 
notable  thickening  of  the  skin,  of  variable  shape  and  dimensions; 
they  may  apppear  at  any  age  but  especially  about  puberty;  they 
are  apt  to  darken  or  multiply  under  the  influence  of  pregnancy, 
uterine  disturbances,  or  exposure  to  sunlight. 

(a)  Liver  spots,  thus  named  on  account  of  their  color,  are  round, 
oval,  or  polylobular  and  may  exceed  the  dimensions  of  the  palm  of 
the  hand;  aside  from  its  pigmentation,  the  skin  is  in  no  way  changed. 

(b)  Ephelides  (p.  323)  are  not  classified  with  nevi  by  the 
majority  of  authors. 

(c)  Lentigo  or  lentigines  are  brown,  black  or  blue  spots,  about  the 
size  of  a  lentil,  situated  on  the  face,  the  neck,  the  shoulders  or  else- 
where; they  are  sometimes  known  in  France  as  "beauty  spots." 
The  old  writers  designated  the  purely  pigmentary  flat  spots  under 
the  name  of  ncevi  spili.  Not  uncommonly,  however,  a  lentigo  is 
perceptible  to  the  touch  and  slightly  prominent;  all  intermediate 
forms  may  even  be  met  with  between  lentigo  and  soft  pigmentary 
verrucous  nevi.  In  the  flat  spots  of  lentigo,  the  pigment  is  localized 
in  the  epidermis  exclusively;  when  the  spots  are  prominent,  pig- 
mentary and  nevic  cells  are  found  both  in  the  epidermis  and  in  the 
cutis  (Fig.  195). 

Exceptionally,  the  skin  is  spattered  with  lentigo-spots  in  the  form 
of  an  abundant  eruption,  constituting  lentiginosis  prof  it  sa. 

(d)  Lentigo  maligna  (infective  melanotic  freckles  of  Hutchinson; 
precancerous  circumscribed  melanosis  of  Dubreuilh)  is  a  pigmentary 
spot  which  may  appear  at  any  age,  by  no  means  exclusively  in  the 
aged,  in  any  region,  although  preferably  on  the  face.  It  has  the 
structure  of  a  diffuse  lentigo,  spreads  slowly  at  first,  then  sooner  or 
later  gives  rise  to  a  nevo-carcinoma  and  accordingly  constitutes  an 
extremely  serious  affection. 

(e)  In  progressive  cutaneous  melanosis,  a  very  rare  disease  which  is 
more  apt  to  attack  the  young,  a  slate-colored  or  bluish  spot  is  seen 
to  spread  slowly,  become  verrucous,  give  rise  to  melanotic  infil- 
tration of  the  glands  and  lead  to  death  after  a  number  of  years  as  a 


606  TUMORS  OF   THE  SKIN 

result  of  visceral  melanosis.  In  this  form,  the  pigment  infiltrates 
the  connective-tissue  cells  of  the  corium. 

The  treatment  of  liver-spots  is  like  that  of  ephelides.  It  would  be 
exaggerated  to  insist  upon  the  destruction  of  all  lentigo  spots,  but 
it  is  advisable  to  watch  them. 

At  any  rate,  it  should  be  kept  in  mind  when  treating  lentigo,  that 
there  is  real  danger  in  repeatedly  irritating  or  incompletely  cauter- 
izing the  spots,  for  such  measures  result  only  too  frequently  in  the 
production  of  melanosis  and  nevus-carcinoma.  (French  Association 
for  Cancer  Research,  November,  1913.)  Superficial  spots  can  be 
destroyed  with  the  galvanocautery ;  carbonic  acid  snow  or  electrolysis 
constitute  the  treatments  of  choice.  Deeper  spots  are  to  be  de- 
stroyed exclusively  by  electrolysis.  Where  there  is  the  slightest 
indication  of  extension  or  malignant  change,  early  wide  excision  is 
the  only  recourse.  Radiotherapy  and  radium  are  not  to  be  recom- 
mended. 

[Any  method  of  treatment  which  does  not  insure  the  removal  or 
destruction  of  every  single  nevus-cell  must  be  condemned.  The 
cells  left  in  the  scars  produced  by  electrolysis  or  other  methods  of 
cauterization  are  subject  to  great  irritation  from  the  strain  of  the 
scar-tissue,  and  the  methods  in  question  necessarily  involve  the 
risk  of  leaving  a  few  cells  intact.  In  practice  no  harm  results  in 
the  majority  of  cases;  but  I  have  seen  three  cases  of  cancer  devel- 
oping in  nevi  treated  by  electrolysis  or  C02-snow.  A  pigmented 
nevus  should  be  left  in  peace  or  else  radically,  surgically,  removed.] 

2.  Tuberous  Non-vascular  Nevi. — These  are  not  simply  spots 
but  genuine  neoplasms  of  variable  dimensions. 

(a)  Soft  verrucose  nevi  (soft  warts,  cellular  nevi). — This  name  is 
applied  to  elevations  of  the  size  of  a  hemp-seed  to  that  of  an  almond, 
more  or  less  prominent,  sometimes  slightly  constricted  at  their  base; 
the  surface  is  smooth  or  grained,  sometimes  hairy;  the  color  is  pink, 
yellowish  or  dusky.  Soft  warts  may  be  congenital,  but  appear  more 
frequently  during  childhood,  increasing  in  size  with  the  approach 
of  old  age.  They  are  especially  common  on  the  face,  the  neck,  the 
thorax  and  in  the  neighborhood  of  the  external  genitals. 

Their  chief  importance  lies  in  their  possible  transformation  into 
cancer  when  they  are  exposed  to  repeated  irritation  or  unskilful 
cauterizations. 

Histological  examination  shows  that  these  nevi  consist  of  an 
infiltration  of  the  cutis  by  round  or  polyhedric  cells  with  a  large 
nucleus,  abundant  protoplasm,  distinctly  epithelioid,  solitary  or 
arranged  in  nests,  columns  or  strands,  representing  the  nevus  cells, 
which  are  sometimes  pigmented.  Virchow  interpreted  these 
cells  as  young  connective-tissue  cells;  Demieville,  as  endothelial 
cells;  Unna  showed  that  they  are  epithelial  and  derived  from  the 


NEVI  667 

rete  mucosum  of  the  epidermis  through  proliferation  and  strangu- 
lation of  the  interpapillary  processes.  This  statement  has  been 
verified  by  numerous  authors  and  I  too  have  been  able  to  confirm 
it.  The  epidermis  itself  is  often  found  to  contain  nests  or  clusters 
of  pigmented  or  non-pigmented  nevus  cells  (Fig.  185).  Hence  the 
malignant  tumors  which  arise  from  these  soft  warts  through  prolifer- 
ation of  the  nevus  cells  can  no  longer  be  regarded  as  sarcomas  of 
connective-tissue  origin,  but  rather  as  epitheliomas  of  a  special 
kind,  nevo-carcinomata. 

(b)  Nevi  Molluscum. — These  are  more  flabby  formations  than  the 
soft  warts,  with  a  thin  epidermis  and  a  wrinkled  surface.  These 
mollusca  may  be  flattened  and  spread  out,  yielding  the  sensation 
of  a  depression  in  the  cutis  on  palpation;  or  they  may  be  slightly 
prominent,  like  lipomas ;  more  frequently  they  are  pedunculated  and 
are  then  called  molluscum  pendulum. 

The  latter,  which  are  very  common,  develop  in  the  period  of 
adolescence  or  sometimes  in  large  numbers  in  the  forties;  they  are 
chiefly  situated  on  the  neck,  the  back,  the  eyelids  and  around  the 
genital  regions.  Their  size  varies  from  that  of  a  pin-head  to  a  pea, 
often  reaching  that  of  a  raisin,  berry  or  a  small  pear.  [Crops  of  these 
small  pendulous  fibromata,  50  to  100  or  more  in  number,  some- 
times develop  in  women  on  the  face,  neck  and  torso,  during  the 
later  months  of  pregnancy,  disappearing  for  the  greater  part  in  the 
course  of  a  year  or  two,  constituting  therefore  a  form  of  dermatosis 
of  pregnancy.  ] 

Fibroma  molluscum;  some  voluminous  nevi  molluscum  form 
large  flabby  tumors,  either  not  very  prominent  and  lobulated  or  on 
the  contrary  hanging  down  in  the  shape  of  a  wallet,  sometimes 
reaching  the  dimensions  of  an  orange  or  a  child's  head. 

When  they  enclose  hard  nodular  strands,  which  usually  are 
thickened  nerves,  they  bear  the  name  of  plexiform  neuromas. 

In  a  considerable  number  of  cases,  the  large  number  of  nevi 
molluscum  or  the  mere  presence  of  fibroma  molluscum  may  suggest 
the  existence  of  an  incomplete  or  abortive  form  of  Recklinghausen's 
disease  which  will  be  described  further  on. 

All  these  nevi  molluscum  are  histologically  made  up  of  a  special 
fibromatous  tissue,  with  fine  connective-tissue  fibers  and  very 
numerous  young  cells,  without  an  elastic  plexus.  They  practically 
never  undergo  a  cancerous  change  [but  myxomatous  degeneration 
is  frequent]. 

(c)  Hard  or  Hyperkeratotic  Verrucous  Nevi. — These  have  been 
described  with  the  circumscribed  keratoses  (p.  206).  Their  structure 
is  that  of  generalized  hyperkeratosis;  nevus  cells  are  only  rarely 
present. 

I  repeat  that  they  may  assume  an  arrangement  as  linear  streaks, 


668  TUMORS  OF  THE  SKIN 

or  ;is  osteo-follicular  keratoses  (p.  4(K>);  and  finally,  the  appearance 
known  as  porokeratosis,  when  they  affect  the  palmar  or  plantar 
regions  (p.  216). 
(d)  Hairy    Nevi   (New,    Pilosi). — An  exaggerated  development 

of  the  hairs,  their  follicles  and  their  sebaceous  glands,  may  be 
encountered  in  the  pigmentary  nevi  and  in  all  the  varieties  of  non- 
vascular tuberous  nevi.  These  hairs  are  often  thick  or  enormous, 
dark  and  curly,  more  or  less  abundant;  giant  comedos,  sebaceous 
cysts  or  small  horny  cysts  may  also  be  seen.  Hypertrichosis  in 
spots  or  on  larger  surfaces,  which  may  constitute  a  partial  furry 
coat,  must  be  included  with  the  hairy  nevi  (p.  405). 

Treatment. — What  has  been  stated  about  the  treatment  of  lentigo 
is  strictly  true  in  all  respects  for  the  soft  warts.  Electrolysis  is  by 
far  the  best  mode  of  intervention  and  yields  the  best  esthetic  results. 
The  treatment  of  the  other  varieties  is  optional;  according  to  the 
cases,  they  may  be  dispersed  or  removed  with  the  galvano-cautery, 
the  bistoury,  carbonic  acid  snow,  etc.  [I  have  already  stated  my 
objections  to  any  except  radical  treatment  for  these  conditions.] 

Neurofibromatosis  or  Recklinghausen's  Disease. — This  is  a  typical 
developmental  and,  strictly  speaking,  nevic  disease,  sometimes 
familial,  having  its  principal  manifestations  in  the  skin  and  the 
hypoderm  (Fig.  188). 

Neurofibromatosis  is  characterized  by  four  sets  of  symptoms: 
( 1 )  Pigmentations,  under  the  form  of  liver  spots,  lenticular  spots  and 
regional  or  diffuse  melanoderma;  (2)  cutaneous  tumors,  scattered 
in  one  region  or  over  almost  the  entire  body,  being  nevi  molluscum 
of  all  varieties  and  dimensions;  they  often  begin  in  the  hypoderm, 
where  they  may  be  recognized  by  a  bluish  spot  and  by  their  con- 
sistence; they  protrude  after  the  fashion  of  a  hernia  through  the 
cutis  and  later  on  become  pedunculated;  (3)  tumors  of  nerves, 
assuming  the  form  of  hard,  rounded  or  spindle-shaped,  sometimes 
moniliform  nodes,  perceptible  along  the  course  of  the  subcutaneous 
nerve-filaments  of  the  forearm,  the  flanks,  the  forehead,  the  neck, 
or  the  thighs;  they  are  due  to  the  development  around  the  nerve- 
sheaths  and  especially  in  the  interior  of  the  latter,  of  a  tissue  like 
that  of  fibroma  molluscum;  (4)  mental  disturbances,  consisting  of  a 
general  intellectual  deterioration  or  loss  of  emotional  control.  |In 
my  experience  mental  disturbances  are  extremely  rare.] 

Numerous  incomplete  cases  occur,  in  which  either  the  tumors  of 
the  nerves  or  the  pigmentations,  etc.,  are  absent.  The  pigmen- 
tations are  of  such  characteristic  appearance,  through  the  associa- 
tion of  the  three  forms  mentioned  above,  that  when  they  are  the 
only  symptoms  present,  a  diagnosis  of  Recklinghausen's  disease  is 
sometimes  justified. 

In  other  cases,  some  of  the  tumors  assume  a  considerable  size 


EPITHELIAL  TUMORS 


0(i9 


and  are  then  designated  as  major  tumors.  They  present  the  appear- 
ance either  of  fibroma  molluscum  or  of  plexiform  neuromata,  or 
even  of  dermatolyses  (p.  372). 


Fig.  188. — Neurofibroma.     Vor^  Recklinghausen's  disease.     (Ormsby. 


Neurofibromatosis  appears  in  the  course  of  childhood  or  adoles- 
cence, develops  in  successive  instalments  and  then  persists  indef- 
initely. Distinct  retrogressions  have,  however,  occurred  in  my 
experience. 

EPITHELIAL  TUMORS 

The  tumors  derived  from  the  epidermis  or  its  adnexa,  hair  follicles 
and  glands,  consist  in  part  of  simple  tissue  hyperplasias,  in  part  of 


670  TUMORS  OF  THE  SKIN 

hyperplasias  with  metaplasia  or  metatypism,  i.  c,  a  more  or  less 
pronounced  modification  of  the  normal  cell  type.  The  statement  is 
justified  only  in  a  very  general  way  that  the  former  follow  a  usually 
benign  course,  whereas  the  latter  are  as  a  rule  of  malignant  character. 

As  a  matter  of  fact,  the  conditions  governing  the  malignancy  of 
tumors,  their  tendency  to  indefinite  invasion  and  generalization, 
are  entirely  unknown  at  the  present  time. 

Papillomata. — The  attempt  has  been  made  to  group  under  this 
term  all  outgrowths  resulting  from  a  proliferative  hypertrophy  of 
the  epidermis  (p.  237).  In  reality,  the  term  papilloma  is  appli- 
cable only  to  an  objective  appearance.  To  state  that  a  cutaneous 
or  mucous  lesion  is  a  papilloma  is  no  more  equivalent  to  a  diagnosis 
than  it  would  be  to  describe  a  disease  as  a  papule  or  a  bulla,  but  it 
simply  describes  an  existing  dermatological  lesion.  This  derma- 
tological  form,  to  which  Chapter  XII  is  devoted,  may  manifest 
itself  under  a  great  variety  of  conditions. 

Common  and  flat  warts,  as  well  as  venereal  warts,  are  almost 
certainly  of  infectious  origin.  The  same  is  true  for  a  considerable 
number  of  the  other  proliferative  dermatoses.  Verrucous  nevi  are 
papillomas  resulting  from  a  local  malformation. 

In  the  angiokeratomas  (p.  fi95)  the  verrucous  condition  is  sec- 
ondary to  the  angiomatous  newformation. 

It  is  an  important  and  noteworthy  fact  that  certain  epitheliomas 
are  papillary  or  begin  with  a  proliferative  stage  of  papillomatous 
appearance. 

Cysts. — Cysts  are  neoplasms  of  a  special  variety  and  result,  not 
from  an  abnormal  multiplication  of  living  constituents,  but  from  an 
accumulation  of  inert  secretory  products  in  an  epithelial  pocket, 
lined  with  a  connective-tissue  membrane;  accordingly,  they  repre- 
sent retention  tumors.    A  distinction  is  made  between  two  classes: 

A.  Epidermic  and  Sebaceous  Cysts. — Their  size  varies  from  that 
of  a  millet-seed  to  that  of  a  hen's  egg;  they  are  intradermic  or 
hypodermic.  Their  consistence  may  be  hard  and  elastic,  or  flabby, 
or  even  fluctuating.  The  skin  which  covers  them  may  be  raised  or 
stretched,  but  usually  retains  its  normal  color;  it  becomes  red- 
dened in  case  of  inflammation. 

The  contents  of  these  cysts  are  opaque  and  pasty,  made  up  for 
the  most  part  of  more  or  less  perfectly  keratinized  epidermic  cells, 
derived  from  their  internal  lining,  which  is  epidermic;  they  also 
contain  fat,  a  direct  product  of  the  developing  epidermic  cells; 
fatty  acid  crystals,  soaps,  cholesterol  and  sometimes  particles  of 
lime  salts.  According  to  its  appearance,  the  contents  are  described 
as  meliceric,  steatomatous,  cholesteatomatous,  or  oily.  Suppuration 
of  the  cysts  caused  by  infection  through  pyococci,  may  lead  to  a 
cure. 


EPITHELIAL  TUMORS  671 

There  are  five  varieties  to  be  described: 

1.  Follicular  cysts  and  sebaceous  cysts,  generally  resulting  from  a 
dilatation  of  the  pilo-sebaceous  canal.  Their  first  stage  is  represented 
by  comedo;  when  more  advanced  they  form  little  yellowish-white 
elevations  which  are  superficial,  umbilicated,  pasty  cysts  that  may 
be  emptied  by  expression. 

2.  Dermoid  Cysts. — These  are  derived  from  an  epidermic  inclusion 
in  the  region  of  certain  embryonic  clefts  and  are  consequently 
situated  especially  at  the  outer  end  of  the  eyebrows,  in  the  neighbor- 
hood of  the  orbit,  on  the  neck,  on  the  perineal  raphe,  the  scrotum, 
etc.    They  may  contain  hair  follicles,  hairs,  sebaceous  glands,  etc. 

3.  Wens. — These  are  sebaceo-epidermic  cysts,  frequently  multiple, 
met  with  only  on  the  scalp  and  on  the  scrotum  and  appearing  only 
in  adult  or  aged  individuals;  they  are  deep  and  present  neither  an 
umbilication  nor  an  orifice.  In  my  opinion,  wens  are  derived  from 
a  congenital  malformation  of  folliculo-glandular  epidermic  buds 
and  should  be  interpreted  as  a  variety  of  nevi;  constituting  cystic 
follicular  adenomatous  nevi. 

4.  Traumatic  Epidermic  Cysts. — These  are  hard,  round,  painless 
tumors,  which  are  encountered  only  on  the  palmar  aspect  of  the 
hands  and  fingers.  These  cysts  seem  to  result,  according  to  the 
explanation  offered  by  Gross  of  Nancy,  from  a  deep  implantation  of 
a  shred  of  epidermis,  under  the  influence  of  a  traumatism.  They 
are  observed  especially  in  laborers  and  require  months  and  weeks 
for  their  development. 

5.  Milium. — The  name  of  milium,  or  grutum,  is  applied  to  white, 
beady  granules  the  size  of  a  pin-head,  which  are  small  epidermic, 
intra-epidermic  or  intra-dermic  cysts.  They  are  observed  as  a 
primary  manifestation  especially  on  the  upper  two-thirds  of  the  face 
and  on  the  genital  organs  of  both  sexes;  or  secondarily  upon  cica- 
trices of  no  matter  what  origin ;  or  as  a  sequel  of  bullous  affections, 
especially  congenital  pemphigus  with  epidermic  cysts  (p.  191). 

Histology  shows  them  to  result  from  the  dilatation  either  of 
sudoriparous  canals  or  hair  follicles.  Primary  milium  is  a  sort  of 
cystic  nevus;  the  milium  of  cicatrices  is  a  retention-tumor. 

The  treatment  of  all  these  epidermic  cysts,  if  any  is  required,  con- 
sists in  their  removal  with  the  bistoury  when  they  are  large  or  with 
the  curette  in  the  case  of  milium.  Wens  may  also  be  treated  by 
injecting  into  their  interior  a  few  drops  of  pure  ether,  or  ether  with 
bichloride  of  mercury,  or  a  zinc  chloride  solution;  this  injection  to 
be  several  times  repeated.  At  the  time  of  the  spontaneous  elimina- 
tion of  the  cyst,  which  takes  place  at  the  end  of  eight  or  ten  days, 
attention  must  be  given  to  the  thorough  extraction  of  the  entire 
epidermic  shell. 


(172  Tl  MORS  OF  THE  SKIN 

B.  Serous  Cysts.  Aside  from  the  hygromas,  the  branchial  cysts 
of  the  neck  and  of  cysticercus  cellnlosa  which  are  not  cysts  of 
epidermic  origin,  this  class  comprises  only  a  single  type: 

Hidrocy stoma.  Hidrocystoma  was  pointed  out  by  A.  Robinson 
in  1884  and  1893  as  a  tense,  firm,  translucid  elevation,  from  which  a 
watery  fluid  is  discharged  on  puncture;  it  is  the  size  .of  a  pin-head 
ni-  a  pea  and  develops  in  large  numbers  on  the  face,  chiefly  in 
middle-aged  women  who  are  exposed  to  the  heat  of  stoves,  etc. 
Hidrocystoma  has  a  tendency  to  disappear  in  the  winter,  reappear- 
ing in  the  spring.  The  little  tumor  consists  of  a  dilatation  of  a 
sudoriparous  canal  and  is  in  my  opinion  of  nevic  character,  there- 
fore constituting  cystic  sudoriparous  adenomata.  Needless  to  say, 
they  have  nothing  in  common  with  dysidrosis  and  sudamina. 

Adenomata. — The  name  of  adenoma  is  at  present  applied  to 
benign  epithelial  newformations,  of  glandular  origin,  whose  con- 
stituents more  or  less  accurately  reproduce  the  texture  of  the 
glands  from  which  they  are  derived. 

The  adenomas  of  the  skin  are  subdivided  into  sebaceous  adenoma 
and  sudoriparous  adenoma  or  hidradenoma.  All  appear  to  have  a 
congenital  malformation  for  their  origin  and  the  name  of  adenoma- 
tous new,  is  eminently  adapted  to  them. 

Adenoma  Sebaceum. — The  most  interesting  form  is  represented 
by  the  .symmetrical  sebaceous  adenomas  of  the  face.  They  appear 
under  the  aspect  of  innumerable  small  tumors,  the  size  of  a  millet- 
seed  to  a  large  pea,  occupying  the  nasogenial  grooves  and  their 
neighborhood,  the  root  of  the  nose  and  the  forehead,  the  chin,  some- 
times the  vicinity  of  the  auditory  meatus,  the  scalp,  etc.  (Fig.  189). 
These  adenomas,  which  are  rarely  congenital,  appear  in  late  child- 
hood, gradually  increasing  and  persisting  indefinitely.  A  white 
variety,  Balzer  type,  is  known,  in  which  the  sebaceous  glands  under- 
go an  atypical  proliferation;  a  red  and  soft  variety,  Pringle  type, 
with  glandular  and  vascular  hyperplasia;  and  a  hard  variety, 
Hallopeau-Leredde  type,  in  which  I  was  able  to  demonstrate  the 
predominance  of  fibrous  tissue,  so  that  this  condition  should  rather 
be  described  as  a  fibro-vascular  nevus.  [Adenoma  sebaceum  is 
often  associated  with  other  congenital  malformations.  Several 
cases  of  association  with  multiple  subcutaneous  fibromas,  teratoma 
of  a  kidney  and  mental  disorders  have  been  recorded.] 

Nonsymmetrical  sebaceous  adenomas  are  seen  in  aged  persons 
or  adults,  scattered  in  variable  number  especially  on  the  scalp,  the 
face,  or  the  back,  from  the  size  of  a  lentil  to  that  of  a  nut  or  larger. 

The  heterotopic  sebaceous  (/lauds  of  the  mucosa'  may  be  considered 
with  the  adenomata;  they  arc  not  infrequently  seen  in  the  mouth, 
on  the  internal  aspect  of  the  lips  and  cheeks.  They  have  the  appear- 
ance of  very  small,  hardly  protuberant  spots,  the  size  of  a  pin-point 


EPITHELIAL   TUMORS 


673 


or  head,  of  a  golden  yellow  or  cream  yellow  color,  solitary  or  in 
abundant  crops.  They  do  not  develop  until  after  puberty.  In 
America  this  anomaly  is  described  under  the  name  of  Fordyce's 
disease.  It  is  of  interest  only  on  account  of  the  diagnostic  errors 
to  which  it  may  give  rise,  in  the  differentiation  from  buccal  lichen 
planus,  etc. 


Fig.  189. — -Symmetrical  sebaceous  adenoma  of  the  face,  Balzer  type. 


Hidradenoma. — These  small  neoplasms — also  designated  as  syringo- 
cystadenoma, etc. — have  two  seats  of  predilection : 

1.  On  the  anterior  surface  of  the  thorax  and  the  neck,  where  we 
described  them  with  Jacquet,  under  the  name  of  hidradenomes 
eruptifs;  they  are  rare,  appearing  between  the  age  of  ten  and 
twenty  years,  as  numerous  solid,  often  oval  protuberances  of  a 
pale  pink  color,  resembling  syphilitic  papules,  but  not  scaly;  they 


674 


T l  MORS  OF   THE  SKIS 


lasl  indefinitely  or  may  disappear.  Lesions  of  the  same  nature  may 
also  be  found  scattered  over  the  abdomen,  on  the  arms  and  on  the 
face. 

2.  Hidradenomas  of  the  lower  eyelids  arc  certainly  much  more 
common.  They  are  met  with  especially  in  adult  or  aged  women. 
They  arc  of  the  color  of  the  skin,  the  size  of  a  pin-head  (Fig.  190) 
and  must  not  be  confused  with  xanthelasma  of  the  eyelids. 

In  both  cases  the  structure  of  the  hidradenomas  is  characteristic; 
the  corium  is  found  to  contain  cylindrical  and  branched  epithelial 
strands,  dilated  here  and  there  into  very  minute  cysts.  They  are 
practically  unanimously  referred  at  present  to  an  abnormal  prolif- 
eration of  rudimentary  undeveloped  sweat-glands.  The  interpre- 
tation implied  by  the  name  of  lymphangioma  tuberosum  multiplex, 
given  by   Kaposi  to  these  small  neoplasms,  is  obviously  erroneous. 


Fig.    190. — Hydradenoma  ot  the  eyelids. 


The  treatment  of  adenomas  in  general  consists  in  ablation  with 
the  bistoury  when  they  are  very  large.  Small  adenomas,  if  the 
patient  desires  their  removal,  should  be  treated  with  electrolytic 
punctures,  or  when  this  is  not  practicable  with  the  curette  and  the 
galvano-eautery. 

Molluscum  Contagiosum. — This  designation,  due  to  BatCman — 
and  preferable  to  the  names  of  acne  varioliformis,  Bazin;  molluscum 
sebaceum,  Hebra;  epithelioma  contagiosum,  Neisser,  etc. — is  applied 
to  peculiar  small  epithelial  tumors  which  are  neither  adenomas  nor 
epitheliomas. 

Molluscum  contagiosum  presents  itself  as  small  hemispherical 
prominent  elevations  of  a  milk-white,  pearly  or  pink  color,  their 
i  ssential  feature  being  that  they  are  umbilicated  on  their  crest. 
Their  size  varies  from  that  of  a  pin-point  to  that  of  a  very  large  pea; 
they  may  become  conglomerated  into  a  tumor  as  large  as  an  almond, 
which  has  a  tendency  to  become  pedunculated.  By  compression 
between  two  fingers  a  creamy  or  pasty  mass  can  be  scmeezed  out 


EPITHELIAL  TUMORS 


675 


of  the  umbilicus,  consisting  under  the  microscope  of  horny  cells  and 
of  refractive  ovoid  corpuscles,  the  so-called  molluscum  bodies. 

The  tumors,  which  vary  greatly  in  number  from  a  few  units  to 
several  hundreds,  are  of  variable  dimensions  and  appear  insidiously, 
in  successive  crops.  They  are  scattered  on  the  face,  especially  on 
the  eyelids,  the  neck,  the  genitals  and  their  neighborhood,  but  may 
be  found  anywhere  (Fig.  191).  Left  untreated  they  persist  indefi- 
nitely, without  any  subjective  symptom,  multiplying  through  auto- 
contagion;  some  of  the  tumors  may  become  inflamed,  suppurate 
and  disappear. 


Fig.   191. — Molluscum  contagiosum  of  the  region  of  the  knee. 


Molluscum  is  observed  [most  frequently]  in  children  and  in  youth- 
ful individuals  of  both  sexes  with  a  delicate  skin. 

Its  contagiousness  is  undeniable;  Vidal,  Retzius,  Hanau  and 
others  have  successfully  inoculated  them;  the  incubation  takes 
several  months.  [Wile  and  Kingery  have  reproduced  them  by 
intracutaneous  injection  of  a  filtrate  (Berkefeld)  of  macerated 
molluscum  turn  or.  J 

Histology  shows  molluscum  contagiosum  to  be  formed  by  fairly 
regular  pyriform  epidermic  lobes  with  their  small  extremity  turned 
toward  the  umbilication.  Notwithstanding  the  gross  analogy  of 
their  configuration,  it  is  an  established  fact  that  these  tumors  never 
develop  from  sebaceous  glands.  The  Malpighian  cells  of  the 
lobules  in  proportion  as  they  are  pushed  back  toward  the  umbilicus, 
undergo  in  part  a  keratinization  with  eleidine,  while  others  undergo 
special  changes  transforming  them  into  molluscum  bodies  of  ovoid 
shape,  which  present  the  reactions  of  colloid  or  keratoid  substances. 


676  TUMORS  OF  THE  SKIN 

Their  special  interest  lies  in  the  misinterpretation  of  these  bodies 
as  psorospermia  or  coecidia,  a  view  which  has  been  proved  false. 

The  condition  actually  is  a  special  dyskeratosis,  related  to  that 
observed  in  psorospermosis  follicularis  and  Bowen's  disease.  The 
corpuscles  are  not  the  carriers  of  the  contagium;  Juliusberg  and 
Borrel  have  shown  that  the  virus  of  molluscum  contagiosum  is 
filtrable. 

The  best  treatment  is  extirpation  with  the  curette,  which  is  easy 
and  leaves  no  cicatrices.  [Expression  between  two  thumb-nails  is 
simple  and  effective.]  Into  the  small  tumors  which  have  first  been 
emptied  by  expression,  the  end  of  a  pointed  match  dipped  in  tinc- 
ture of  iodine  may  be  introduced.  When  the  tumors  are  small  and 
very  numerous,  applications  of  iodine  tincture,  soft  soap,  or  cam- 
phorated alcohol  may  prove  sufficient. 

Epitheliomata. — Cutaneous  epitheliomas  are  tumors  resulting  from 
an  atypical  proliferation  of  the  epidermis  and  of  its  adnexa.  They 
have  also  been  designated  by  the  names  of  epithelial  cancers, 
cancroids,  formerly  as  polyadenomas,  erosive  ulcers,  noli  me  tangere; 
abroad,  especially  in  Germany,  they  are  all  grouped  under  the  head- 
ing of  carcinomata,  whereas  in  France  the  latter  term  is  reserved 
for  the  malignant  and  invasive  cancers. 

In  the  following  brief  account  I  shall  include  the  epitheliomas  of 
the  buccal  cavity  as  well  as  those  of  the  external  genital  organs,  etc., 
which  are  equally  of  dermatological  interest. 

Among  the  highly  multiple  clinical  forms  of  epithelioma,  some 
possess  extreme  malignancy  while  others  on  the  contrary  are  abso- 
lutely benign.  These  will  have  to  be  very  carefully  differentiated. 
It  must  be  emphasized,  however,  that  even  epitheliomas  of  a 
malignant  character  begin  as  a  rule  as  an  apparently  insignificant 
lesion,  readily  amenable  to  early  treatment.  There  is  no  knowledge 
of  greater  practical  importance  for  the  physician  than  familiarity 
with  the  mode  of  onset  of  cancers;  when  properly  forewarned  he 
will  know  how  to  caution  his  patients  against  the  possible  gravity 
of  a  trifling  "sore"  and  to  rid  them  of  it  in  time. 

Clinical  Forms. — The  attempts  which  have  been  made  to  find  in 
the  histological  structure  of  the  various  forms  of  epitheliomas  an 
explanation  of  their  widely  divergent  course  have  been  only  partially 
successful.  The  classification  which  I  proposed  at  the  International 
Congress  in  1904,  although  based  upon  the  histological  structure, 
takes  largely  into  account  the  objective  features  and  the  develop- 
mental tendencies  of  each  kind,  namely  those  characteristics  which 
possess  the  greatest  practical  importance.  This  classification  is 
here  repeated. 

1.  Lobular  or  Spinocellular  Epithelioma. — In  this  first  class,  the 
neoplastic  masses  are  usually  arranged  in  elongated  and  enlarged 


EPITHELIAL  TUMORS  677 

interpapillary  buds,  or  in  lobules  and  in  wide  strands;  they  are 
made  up  essentially  of  Malpighian,  prickle  or  spinous  cells;  these 
cells  undergo  the  usual  epidermic  evolution,  with  formation  of 
keratohyaline,  becoming  keratinized  into  horny  cells  and  often  into 
epidermic  pearls.    This  class  is  subdivided  into  two  types: 

A.  Superficial  Proliferative  Type  or  Papillary  Epithelioma. — This 
type  comprises: 

(a)  Homy  papillary  epithelioma,  which  develops  in  healthy  skin, 
or  not  infrequently  on  a  senile  keratosis.  It  is  encountered  in  all 
regions  but  especially  in  the  face,  on  the  lips,  the  neck,  the  back 
and  on  the  dorsal  aspect  of  the  extremities.  It  begins  as  a  verrucous 
elevation  and  persists  a  long  time  in  this  condition;  then,  almost 
invariably  in  connection  with  traumatism,  it  spreads  as  a  protuber- 
ant disk  bordered  by  a  raised  and  hem-like  margin,  the  center  being 
studded  with  villous  elevations  covered  by  adherent  horny  crusts. 
The  glands  remain  intact  for  a  long  time.  This  epithelioma  bleeds 
readily,  may  ulcerate  and  finally  leads  to  cancroid. 

(b)  Cornu  cutaneum — that  is  to  say,  senile  horny  excrescences, 
for  there  exists  a  juvenile  form  belonging  to  the  class  of  hyper- 
keratotic  nevi  (p.  206) — is  a  papillary  epithelioma  with  exuberant 
hyperkeratosis.  These  horns  are  of  extremely  variable  size  and  some- 
times resemble  a  ram's  horn  from  every  point  of  view,  including 
the  curvature.  They  develop  in  healthy  skin  or  on  senile  keratosis, 
chiefly  in  the  face,  on  the  scalp,  the  glans  and  the  prepuce.  Their 
base  may  be  surrounded  by  a  rose-colored  border.  Their  growth  is 
usually  very  slow;  when  they  fall  out  or  are  removed,  they  will 
grow  again.  The  histological  lesions  are  those  of  papillary  epithe- 
lioma, more  or  less  pronounced;  the  horn  itself  is  formed  by  agglu- 
tinated cellular  columns;  it  is  softer  in  its  center.  These  growths 
may  develop  into  cancroid  and  this  contingency  must  be  kept  in 
mind  for  the  treatment. 

(c)  Naked  papillary  epithelioma,  without  a  horny  covering,  is  met 
with  on  the  lips,  the  buccal  mucosa,  the  glans  and  the  vulva;  its 
surface  is  red,  velvety  and  glistening.  It  follows  a  slow  and  for  a 
long  time  benign  course,  but  may  become  ulcerated  and  pass  into 
cancroid. 

It  is  necessary  to  guard  against  confusion  of  this  variety  of 
epithelioma  with  the  proliferative  syphilides,  with  tuberculous  lupus 
of  the  mucous  membranes,  etc.  Examination  by  biopsy  shows  a 
marked  increase  of  the  interpapillary  buds  in  width  and  in  height, 
with  a  very  moderate  cellular  infiltration  in  the  upper  portion  of  the 
cutis. 

B.  Deep  Type  or  Cancroid  Epithelioma. — This  is  the  penetrating, 
infective,  malignant  form  of  epithelioma  of  the  skin  and  the  mucous 
membranes  with  a  Malpighian  lining. 


67 


TUMORS  OF  THE  SKIN 


It  develops  especially  at  the  orifices;  on  the  lips,  on  the  tongue 
(Fig.  71 )  and  on  the  floor  of  the  mouth,  where  it  appears  as  a  com- 
plication of  leukoplakia,  it  is  known  as  smokers'  cancer;  it  is  not 
uncommon  at  the  amis  and  on  the  penis,  but  may  occur  anywhere, 
notably  on  scar  tissue  and  on  lupus  vulgaris. 

When  cancroid  does  not  result  from  the  malignant  evolution  of  a 
papillary  epithelioma,  but  originates  in  healthy  skin,  it  is  at  first 
a  grayish  tubercle  covered  with  a  scale  or  a  small  crust.    Under  the 


. 


Fig.  192. — Horny  lobular  epithelioma,  spinocellular  epithelioma,  or  cancroid, 
developing  on  leukoplakia  of  the  tongue.  A,  leukoplakia;  B,  raised  border;  C, 
erosion;  D,  lobulated  masses;  E,  epidermic  pearl;  F,  bloodvessel  and  plasma-cell 
infiltration;  G,  nerve;  H,  muscle  tissue.      X  38. 


influence  of  scratching  or  traumatisms,  it  increases  in  extent  and  in 
depth;  its  crest  becomes  reddened  and  ulcerated.  Promptly  a 
tumor  forms,  the  size  of  a  cherry-pit  or  a  hazel-nut,  hard,  imbedded 
in  the  skin  as  well  as  protuberant.  Its  borders  are  raised  and  swollen 
and  usually  more  or  less  hyperkeratotic.  On  the  central  area  appears 
first  an  erosion,  then  a  perpendicular  ulceration,  which  is  irregular, 
fissured,  grayish  and  bleeds  easily. 

Yellowish  granules  or  filaments,  known  as  "pearls"  composed  of 
horny  cells  and  epidermic  globules,  may  be  visible  and  can  some- 


EPITHELIAL  TUMORS  679 

times  be  squeezed  out.  There  may  be  pain  on  pressure  and  move- 
ment. The  glands  rapidly  become  enlarged.  I  have  described 
elsewhere  how  this  cancer  develops  on  leukoplasic  mucous  mem- 
branes (p.  221). 

Histologically,  the  classical  structure  of  lobulated  horny  pavement- 
cell  epithelioma  is  seen  (Fig.  192).  The  large  cylinders  which  pene- 
trate into  the  depth  of  the  tissues,  where  they  form  an  irregular 
lobulated  network  with  large  meshes,  are  apparently  derived  from 
interpapillary  buds  or  from  pilo-sebaceous  follicles.  They  almost 
invariably  enclose  collections  of  lamellar  cells,  concentrically 
arranged  after  the  manner  of  an  onion,  known  as  epidermic  pearls; 
more  or  less  numerous  dyskeratotic  cells  (p.  230)  are  regularly 
demonstrable.  The  stroma  has  a  variable  structure,  but  is  rather 
scanty  as  a  rule.  At  the  circumference,  plasmocytes  are  abundantly 
present.  Neoplastic  strands  having  the  same  structure  as  the  original 
tumor  may  be  found  in  the  lymph  channels. 

The  tumor  ultimately  increases  in  depth,   the  ulcer  becomes 
gangrenous,  the  infected  cancerous  glands  may  open  externally. 
Death  occurs  in  marasmus  or  as  the  result  of  hemorrhage. 
Generalization  in  the  viscera  is  rare. 

The  calcified  epithelioma  of  Malherbe  is  a  rare  and  very  peculiar 
variety  of  spinocellular  epithelioma  in  which  the  epithelial  lobes 
undergo  a  total  infiltration  with  lime-salts.  It  develops  as  a  rule 
at  the  expense  of  old  sebaceous  cysts,  wens  or  dermoid  cysts  and 
consists  of  masses  of  stony  hardness  which  grow  very  slowly.  Unless 
it  undergoes  transformation  into  ordinary  cancroid,  it  follows  a 
benign  course. 

2.  Tubular  or  Baso-cellular  Epitheliomata. — In  this  group  the  neo- 
plastic masses  assume  a  very  variable  arrangement,  as  narrow 
irregularly  branching  strands,  in  tubules,  in  leaf-like  lobules  with 
tapering  processes,  or  as  a  network,  etc.  (Fig.  193) ;  their  continuity 
with  the  covering  epidermis  or  with  the  pilo-sebaceous  follicles  is 
often  demonstrable.  In  the  center  of  these  masses,  small  foci  of 
mucous  or  colloid  degeneration  are  sometimes  seen  which  must  not 
be  mistaken  for  epidermic  pearls.  The  neoplasm  is  composed 
exclusively  of  small  oval  or  spindle-shaped  epithelial  cells,  taking  a 
deep  stain,  with  few  or  no  connecting  filaments;  briefly,  presenting 
the  appearance  of  the  basal  cells  of  the  epidermis.  The  stroma  is 
variable,  often  fibrous  and  sometimes  mucous  or  embryonic. 

This  kind  of  epithelioma  is  common  in  all  persons  of  advanced 
years  and  in  the  aged,  especially  in  connection  with  senile  keratosis. 
Its  seat  of  election  is  on  the  upper  two-thirds  of  the  face,  where 
four-fifths  of  all  epitheliomas  are  tubular;  it  is  also  encountered, 
although  more  rarely,  on  the  lips,  the  tongue,  in  the  pharynx,  on  the 
chest,  the  genital  organs,  etc. 


6S0  TUMORS  OF  THE  SKIN 

The  onset  is  usually  in  the  form  of  an  insignificant  papule,  which 
originates  in  healthy  skin  or  on  a  patch  of  senile  keratosis;  there  is 
a  smooth,  yellowish  or  grayish,  pearly  elevation,  firm  to  the  touch, 
the  size  of  a  pin-head  or  a  lentil.  It  may  resemble  a  Hat  wart,  a 
cellular  nevus,  a  sebaceous  or  sudoriparous  adenoma.  A  vague 
tingling  sensation  causes  scratching;  the  papule  becomes  excoriated 
and  covered  with  a  constantly  renewed  crust  or  it  may  remain 
ulcerated.  Its  growth  is  very  slow  for  a  few  months  or  even  for 
several  years,  until  quite  suddenly  it  becomes  more  rapid. 


Fig.  193. — Tubular  epithelioma  (baso-cellular)  of  the  cheek,  with  the  clinical 
features  of  flat  cicatricial  epithelioma.  Note  the  branched  epithelial  strands,  made 
up  of  basal  cells;  their  continuity  with  the  surface  epidermis  and  with  a  bud  tra- 
versed by  a  sweat-channel ;  the  erosion  covered  with  a  crust  on  the  right  side  in  the 
illustration;  on  the  lefl  part  of  a  mass  which  encloses  a  focus  of  mucoid  degeneration. 
The  neoplasm,  which  causesno  protuberance,  occupies  the  entire  cutis  down  to  the 
level  of  t  he  sudoriparous  glomeruli  and  the  vessels  of  the  subcutaneous  plexus.    X  38. 

Although  very  readily  curable  in  its  incipient  stages,  by  man}' 
kinds  of  treatment,  this  form  of  skin  cancer  nevertheless  possesses 
extreme  malignancy;  it  may  become  mutilating  and  incurable 
when  it  remains  unrecognized,  when  intervention  comes  too  late 
or  the  treatment  is  inappropriate.  Its  malignancy  is  purely  local, 
however,  glandular  enlargement  and  metastases  being  invariably 
absent. 


EPITHELIAL  TUMORS 


681 


Although  constituting  a  single  histological  and  nosological  species, 
basocellular  epithelioma  tends  to  take  an  extremely  variably  course, 
so  that  it  presents  itself  clinically  under  a  highly  variegated  aspect, 
as  tubercles  surrounding  a  cicatrix,  as  an  eroded  surface,  an  ulcer 
or  a  tumor;  these  configurations  may  moreover  coexist  or  follow 
one  another.    The  following  types  may  be  described. 

(a)  Flat  cicatricial  epithelioma  while  spreading  becomes  depressed 
at  its  center,  which  undergoes  sclerotic  atrophy.  After  a  certain, 
sometimes  very  protracted  length  of  time,  it  presents  the  appear- 
ance of  a  rounded  or  rather  irregular  cicatricial  patch,  bordered  by 
a  seam  or  chaplet  of  small  grayish,  scaly  or  smooth,  more  or  less 
translucid  elevations,  owing  to  which  it  is  also  known  as  pearly 
epithelioma.  Not  infrequently,  rather  shallow,  flat  or  granulating, 
slightly  bleeding  ulcerations  form  on  the  borders  and  gradually 
invade  the  vicinity  (Fig.  194).  The  ulcer,  bordered  or  not  with 
pearly  granules,  often  heals  on  one  side  while  it  extends  on  the  other, 


Fig.  194. — Cicatricial  flat  epithelioma  of  the  temple.  Behind,  on  the  side  of  the 
scalp  and  ear,  a  cicatricial  surface  is  seen,  interspersed  and  bordered  with  pearly- 
elevations;  in  front,  on  the  side  of  the  eye,  there  is  a  serpiginous  ulceration. 


destroying  the  eyelids,  the  eyeball,  the  cartilages  of  the  nose  and 
even  the  bones;  it  gradually  causes  enormous  and  frightful  muti- 
lations. I  have  observed  cases  which  had  lasted  for  twenty  and 
thirty  years.  The  tendency  to  recurrences,  after  an  apparent  cure, 
is  extremely  pronounced. 

(b)  Pagetoid  epithelioma  is  far  from  common,  but  important  to 
know  on  account  of  the  diagnostic  errors  to  which  it  is  subject;  it 
presents  a  pinkish  surface,  distinctly  circumscribed  by  rounded 
borders  marked  by  a  filiform  margin,  its  area  being  spattered  with 
small  scales  and  crusts,  resting  upon  an  atrophic  cutis.  Its  growth 
is  extremely  slow.  I  have  observed  it  only  on  the  face  and  on  the 
back  of  aged  individuals.  It  might  be  confused  with  senile  keratosis, 
lupus  erythematodes,  psoriasis  and  especially  with  Paget's  disease, 
or  with  the  atrophic  spots  of  Bowen's  disease.  Biopsy  reveals 
more  or  less  widely  separated  proliferations  of  basocellular  epithe- 
lioma. 


G82  TUMORS  OF  THE  SKIN 

(c)  Rodent  ulcer — or  ulcus  rodens — is  characterized  by  a  shallow 
and  serpiginous  ulceration,  with  a  slightly  indurated  base,  without  a 
pearly  elevation  and  a  very  slow  course.  Only  very  fine  epithelio- 
matous  tubules  are  seen  in  histological  sections. 

ill)  Epithelioma  terebrans  may  be  the  outcome  of  one  of  the 
preceding  varieties  or  it  may  set  in  primarily;  the  newformation 
and  ulceration  advance  in  depth  rather  than  superficially;  craters 
and  often  very  deep  oozing  cavities  appear,  with  a  red  granular 
surface,  surrounded  by  a  limited  induration  (Fig.  95).  Although 
very  destructive,  mutilating  and  painful,  this  form  likewise  possesses 
a  merely  local  malignancy;  the  glands  generally  remain  intact  as 
well  as  the  general  health.  Many  months  and  years  may  pass  before 
the  patient  succumbs  to  hemorrhage  or  complications  of  one  kind 
or  another. 

(e)  Proliferative  tubular  epithelioma,  which  is  less  common,  gives 
rise  on  the  contrary  to  a  genuine  tumor,  in  the  form  of  an  eroded  and 
puckered  macaroon-shaped  elevation,  or  a  protuberance  the  size  of 
a  pea,  a  hazel-nut,  or  rarely  a  large  chestnut,  sometimes  peduncu- 
lated, of  firm  consistence,  with  an  ulcerated  and  bleeding  or  crusted 
surface.  This  proliferation  is  sometimes  seen  to  develop  rather 
rapidly  at  some  point  of  a  slowly  growing  flat  epithelioma. 

(/)  Cylindroma  of  Billroth  and  Malassez,  is  really  an  atypical 
variety  of  the  preceding  form  in  which  the  stroma  undergoes  a 
mucous  and  hyaline  degeneration;  there  is  a  formation  of  trans- 
lucid  cylinders  and  clear  ovoid  proliferations  which  invade  and 
push  back  the  epithelial  masses,  resulting  in  peculiar  histological 
appearances  which  have  been  variably  interpreted,  as  shown  by  the 
numerous  denominations  of  these  tumors,  such  as  siphonoma, 
endothelioma,  plexiform  sarcoma,  angiosarcoma,  etc.  Cylindro- 
matous  tumors  are  situated  especially  on  the  scalp,  in  the  middle  of 
the  face,  or  in  the  buccal  cavity;  they  are  sometimes  voluminous 
often  multiple  and  rarely  undergo  ulceration.  Their  prognosis  is 
the  same  as  that  of  the  other  tubular   epitheliomata. 

3.  Nevo-cellular  Epitheliomas  or  Nevo-carcinomata. — From  the 
purely  histological  point  of  view,  the  cellular  nevi  themselves  are 
benign  nevo-cellular  epitheliomas. 

These  nevi,  whether  pigmented  or  not,  verrucous  or  smooth, 
hairy  or  glabrous,  are  sometimes  the  starting-point  of  malignant 
tumors  in  adult  and  aged  individuals;  it  has  seemed  to  me  that  the 
face  and  the  [heels  and]  plantar  region  of  the  feet  are  the  two 
elective  foci  of  this  transformation. 

The  tumor  then  is  seen  to  enlarge  in  size  and  becomes  painful; 
its  circumference  is  reddened  or  becomes  the  seat  of  a  melanotic 
pigmentation.  Early  and  more  or  less  rapidly  invasive  ulceration 
follows.     Similar  small  tumors  promptly  begin  to  multiply  in  the 


EPITHELIAL  TUMORS  683 

vicinity,  then  at  a  distance.  In  case  the  primary  neoplasm  was 
pigmented,  generalization  takes  place  by  the  appearance  either  of 
numerous  secondary  pigmented  or  non-pigmented  tumors  or  of 
extensive  localized  or  metastatic  pigmentations,  or  of  a  generalized 
melanosis.  The  glands  are  promptly  involved  in  this  form,  which 
often  possesses  great  malignancy;  metastases  in  the  viscera,  notably 
in  the  liver  and  lungs,  is  of  common  occurrence. 

The  histological  structure  of  these  malignant   tumors  derived 
from  nevi  is  peculiar  (Fig.  195). 


It A. 


Fig.  195. — Histology  of  a  pigmentary  nevus  (lentigo)  and  of  the  incipient  nevo- 
carcinoma.  Section  from  the  border  of  the  tumor,  c.  n.  d.,  nevus  cells,  pig- 
mented or  clear,  in  the  cutis;  c.  n.  e.,  pigmented  nevus  cells  in  the  intra-epidermic 
tissue ;  p,  infiltration  of  plasma  cells  at  the  circumference  of  the  tumor ;  x,  transition 
zone  between  the  nevus  and  the  nevo-carcinoma;  n.  c,  tissue  of  the  nevo-carcinoma 
of  sarcomatous  appearance;  k,  portion  of  an  epidermic  cyst  which  was  contained  in 
the  nevus.      X  57. 

Their  constituents  are  globular  or  spindle-shaped,  sometimes 
pigmented,  arranged  in  compact  masses,  in  imperfectly  outlined 
strands  or  in  alveoli;  sometimes  the  appearance  is  entirely  that  of  a 
sarcoma. 

For  a  long  time  such  cases  were  interpreted  as  sarcomatous  tumors 
and  designated  as  melanotic  sarcoma  or  melano-sarcoma.  The  name 
of  nevo-carcinoma,  proposed  by  Unna,  who  showed  the  epithelial 
origin  of  nevus  cells  and  consequently  of  the  neoplasms  derived 
from  them,  is  much  better  justified  (see  my  paper  on  nevo-carcinoma, 
in  Bulletin  de  V Assoc,  f rang,  du  cancer,  November,  1913). 

4.  Secondary  Carcinoma.— Metastatic  epitheliomas  are  also  met 
with  in  the  skin,  although  but  rarely,  derived  from  operated  or 


084  TUMORS  OF  THE  SKIN 

non-operated  cancers  of  the  breast,  or  from  internal  cancers,  as 
the  result  of  neoplastic  embolisms  in  the  vessels. 

They  are  characterized  by  hard,  pinkish,  purplish  or  brownish 
elevations,  the  size  of  a  pin-head  to  that  of  a  hazel-nut;  solitary  at 
first,  they  gradually  become  confluent  in  irregular,  mammillated 
surfaces  (Velpeau's  cancer  en  cuirasse).  They  are  apt  to  ulcerate, 
proliferate  and  become  fungoid.  Sometimes  an  extensive  patch  or 
surface  of  scirrhus  cancerous  lymphangitis  develops,  which  may 
resemble  a  patch  of  scleroderma. 

The  histological  characteristic  of  secondary  carcinoma  of  the 
skin  is  that  the  neoplastic  masses,  made  up  of  cells  suggesting  the 
primary  tumor  cells,  are  without  connection  with  the  surface  or 
folliculo-glandular  epidermis;  they  are  arranged  in  branching  tracts 
following  the  vascular  and  lymphatic  channels;  later  on,  alveoli 
are  hollowed  out.  The  dermic  stroma  presents  at  the  onset  prac- 
tically no  indication  of  any  reaction,  but  subsequently  becomes 
sclerotic  and  retracted. 

Etiology  and  Pathogenesis  of  the  Epitheliomata. — We  know  that 
cutaneous  epitheliomas  practically  never  develop  until  after  the  age 
of  forty  years  and  more  frequently  in  males;  when  they  occur  in 
more  youthful  patients  these  will  be  found  to  have  suffered  as  a 
rule  from  a  precancerous  affection.  The  part  played  by  heredity 
is  doubtful. 

The  cause  of  the  facial  localization  of  the  vast  majority  of  epithe- 
liomata of  the  skin  is  not  known;  undoubtedly  it  is  to  a  considerable 
extent  because  this  region  is  the  seat  of  election  of  senile  degener- 
ation and  leukoplakia;  because  it  is  particularly  exposed  to  trauma- 
tisms, to  inoculations  of  infectious  germs,  to  the  influence  of  atmos- 
pheric factors  and  especially  of  light,  which  seems  to  exert  a 
favoring  action  [and  possibly  because  the  complicated  planes  of 
embryonic  growth  in  the  face  afford  a  ready  opportunity  for  the 
misplacement  of  epithelial  cells]. 

The  direct  cause  of  epithelioma  and  cancerous  tumors  in  general 
still  remains  unknown. 

The  parasitic  or  exogenic  theory,  although  very  tempting  at  first 
sight,  rests  on  no  reliable  basis.  None  of  the  hitherto  described 
cancer  parasites  have  withstood  criticism.  The  coccidia  which  were 
supposed  to  have  been  discovered,  turned  out  to  be  merely  forms  of 
cellular  degeneration  and  dyskeratosis.  We  know  that  there  exists 
in  mice  a  form  of  contagious  cancer,  which  is  inoculable  and  can 
be  indefinitely  transplanted  into  animals  of  the  same  species,  certain 
breeds  of  mice  being  predisposed  to  it;  but  the  causative  agent  has 
never  been  isolated.  There  is  nothing  to  justify  the  statement  that 
human  cancers  are  of  infectious  origin.  Borrel  reported  in  small 
epitheliomas  of  the  face  the  usual  presence  of  a  demodex,  which  he 
believes  to  be  the  possible  carrier  of  unknown  pathog  nic  germs  (?) 


EPITHELIAL  TUMORS 


685 


Opposed  to  this  interpretation  are  the  cellular  or  endogenic 
theories,  which  assume  aberrant  embryonic  germs  and  cellular 
heterotopia,  with  Cohnheim  and  Ribbert,  or  a  loss  of  balance  of  the 
tissue  constituents,  or  their  abnormal  fertilization,  according  to 
Hallion,  etc. 

It  must  be  admitted  that  the  conception  of  precancerous  states 
is  rather  an  argument  against  the  parasitic  theory.  Perhaps,  epi- 
thelioma is  merely  the  outcome  of  various  processes,  sometimes 
of  teratological  or  dystrophic  character;  in  other  cases  of  ordinary 
inflammatory  or  even  specific  character. 


-Multiple  epitheliomatosis  of  the  face  on  senile  keratosis, 
in  the  St.  Louis  Hospital,  Paris. 


After  a  cast 


Precancerous  Affections. — This  designation  is  applied  to  patho- 
logical conditions  which  are  so  frequently  the  origin  of  cancers  that 
this  coincidence  cannot  be  the  effect  of  a  mere  accident. 

These  affections  are  of  various  kinds  and  have  been  described  in 
the  chapter  to  which  they  belong.  I  shall  therefore  restrict  myself 
in  this  paragraph  to  a  general  summary. 


686  TUMORS  OF  THE  SKIN 

1.  Xevi  are  malformations  which  lead  to  nevo-carcinoma. 

2.  Various  dystrophies  are  precancerous. 

The  term  of  senile  multiple  epitheliomatosis  (Pig.  196)  serves  to 
designate  a  very  common  syndrome  consisting  of  the  simultaneous 
or  successive  development  of  several  epitheliomas  at  the  site  of 
senile  keratoses  (p.  209)  and  on  a  soil  of  senile  degeneration  of  the 
skin.  These  epitheliomas  are,  as  a  rule,  of  tubular  type,  sometimes 
papillary  or  rarely  mixed.  Presenile  dystrophy  is  followed  by  similar 
sequelae  (p.  358). 

Xeroderma  pigmentosum  (p.  355)  and  up  to  a  certain  point  the 
chronic  radiodermatitides  (p.  454)  lead  to  an  analogous  picture;  in 
the  latter  case,  the  epitheliomas  as  a  rule  are  horny  and  papillary, 
later  on  cancroid. 

Arsenical  cancer  is  simply  a  progressive  and  imperceptible  trans- 
formation of  verrucous  arsenical  keratoses  (p.  213)  into  multiple 
epitheliomas,  usually  of  a  horny  papillary  type. 

3.  Leukoplakia  is  entitled  to  special  mention  among  the  pre- 
cancerous affections,  as  it  is  the  customary  although  not  constant 
substratum  of  the  lobulated  epitheliomas  of  the  mouth,  the  genital 
regions  and  the  anus  (p.  221). 

4.  Epitheliomas  of  various  types  likewise  develop,  although  much 
less  commonly,  on  very  different  dermatoses,  among  which  must 
be  quoted:  lupus  vulgaris;  cicatrices  of  any  origin,  but  especially 
the  old  cicatrices  of  burns;  the  occupational  dermatosis  of  chimney- 
sweeps, workers  with  tar  and  paraffin,  coal-heavers;  dermoid  cysts 
and  wens;  ulcers  and  fistulas,  obstinate  psoriasis,  lupus  erythema- 
todes,  etc. 

5.  Among  the  dyskeratoses  (p.  230),  there  are  two  which  evidently 
represent  precancerous  affections:  In  Paget' s  disease,  the  termina- 
tion in  cancer  is  the  rule,  sometimes  after  a  very  long  time,  it  must 
be  admitted.  In  Bourn 's  disease  half  of  the  known  cases  (three  of 
the  six  cases  published  by  Bowen  and  by  myself)  have  led  to  can- 
cerous transformation. 

Diagnosis  of  the  Epitheliomas. — The  clinical  forms  are  too  varied 
to  admit  of  completeness  in  this  connection.  At  the  onset,  the 
epitheliomas  must  be  distinguished  from  warts,  nevi,  etc.  Cancroid 
sometimes  resembles  syphilitic  chancre,  or  the  tuberculo-ulcerative 
tertiary  syphilides,  or  even  tuberculous  ulcer.  Its  neoplastic  char- 
acter must  be  kept  in  mind;  it  is  an  ulcerated  tumor,  not  an  ulcera- 
tion with  an  indurated  base.  Flat  cicatricial  epithelioma  is  really 
easily  distinguished  from  the  eczematides,  from  lupus  erythema- 
todes,  from  tuberculosis  verrucosa;  more  commonly,  the  question  of 
a  tubercular  syphilide  may  arise;  but  the  principal  difficulty  which 
occurs  in  this  connection  is  to  decide  whether  or  not  a  given  spot  of 
keratosis  is  already  epitheliomatous. 


EPITHELIAL  TUMORS  687 

Under  all  circumstances,  I  here  repeat  the  definite  and  absolute 
rule  which  I  have  previously  formulated,  to  the  effect  that  when 
there  is  the  least  suspicion  of  epithelioma,  recourse  should  be 
had  to  biopsy  for  the  certainty  which  this  method  alone  can  supply, 
thereby  permitting  the  timely  institution  of  appropriate  treatment 
(c/.,p.222).< 

[The  American  Society  for  the  Control  of  Cancer  has  formulated 
the  rule  never  to  cut  into  a  suspected  growth  without  immediately 
sealing  the  cut  surfaces  by  means  of  the  actual  cautery;  to  employ 
frozen  sections  for  making  an  immediate  diagnosis  to  be  followed  by 
radical  operation  at  the  same  sitting,  if  indicated;  and  under  no 
circumstances  to  allow  more  than  twenty-four  hours  to  elapse 
between  the  biopsy  and  the  operation  if  the  diagnosis  is  cancer.  The 
risk  of  dissemination  in  cutaneous  cancers  is,  however,  very  small.] 

Prognosis  and  Treatment. — Although  the  prognosis  depends  essen- 
tially upon  the  anatomo-clinical  type,  it  is  no  less  true  that  every 
epithelioma,  no  matter  what  its  kind,  should  be  completely  removed 
or  entirely  destroyed.  Internal  treatment,  arsenic,  mercury,  etc.,  is 
a  waste  of  valuable  time;  iodide  medication  is  decidedly  harmful. 
Local  intervention  is  what  is  required.  The  different  forms  of  epi- 
theliomata,  however,  are  not  amenable  to  the  same  methods. 

Spino-cellular  Epithelioma. — Papillary  epithelioma  must  be  treated 
by  surgical  removal,  which  is  easy  and  provides  rapid,  reliable 
results. 

Cancroids  demand  the  earliest  possible  and  very  wide  surgical 
excision ;  as  a  rule,  the  corresponding  glands  must  be  removed  at  the 
same  time.  Radiotherapy  is  not  applicable  to  lobulated  epithe- 
liomata  and  is  certainly  harmful  in  these  cases.  The  few  cured  cases 
of  lobulated  epithelioma  through  the  .T-rays  or  radium  which  have 
been  reported,  leave  some  doubt  in  the  mind  for  lack  of  sufficient 
histological  demonstration  of  the  spino-cellular  character  of  the 
tumor.  On  the  contrary,  I  have  repeatedly  noted  the  occurrence 
of  frightful  aggravations  under  the  action  of  this  treatment.  In 
the  case  of  absolutely  inoperable  tumors,  however,  radiotherapy 
or  radium  may  be  utilized  for  the  relief  of  the  pains.  Technical 
improvements  of  radium  therapy  and  radiotherapy  have  on  several 
occasions  been  promised,  which  would  guarantee  reliable  cures  even 
of  spino-cellular  epitheliomas;  this  progress  may  indeed  be  hoped 
for,  but  for  the  present  a  skeptic  attitude  is  justified. 

Baso-cellular  Epithelioma. — Flat  cicatricial  epithelioma  and  rodent 
ulcer  are  the  triumphs  of  radiotherapy;  innumerable  cases  have  thus 
been  permanently  cured,  with  excellent  esthetic  results.  Preference 
should  be  accorded  to  the  method  of  massive  doses  and  filtration 
through  aluminum  if  necessary,  to  be  repeated,  provided  the  toler- 
ance of  the  skin  permits  (p.  453);  the  treatment  should  aim  in  a 


CSS  TUMORS  OF  THE  SKIN 

genera]  way  at  keeping  the  tumor  saturated  with  radiations  until 
after  an  apparent  cure  lias  been  obtained.  Should  relapses  occur, 
they  will  yield  to  renewed  treatment. 

In  proliferative  tubular  epithelioma,  it  is  advisable  first  to  excise 
the  larger  portion  of  the  tumor,  in  order  to  reduce  as  far  as  possible 
the  work  to  be  accomplished  by  the  radiations. 

A'-rays  and  radium  institutes  are  now  so  numerous  in  all  countries 
that  recourse  to  them  can  almost  invariably  be  had.  It  is  useful 
to  know,  however,  that  baso-cellular  epithelioma  can  be  cured  by 
other  procedures.  Surgical  operation  is  not  the  best,  for  in  the 
tubular  forms  it  is  necessary  to  pass  rather  considerably  beyond 
the  borders  and  the  floor  of  the  neoplasm,  which  leads  to  deplorable 
mutilations;  in  case  of  a  recurrence,  the  additional  operations  will 
involve  still  greater  difficulties.  Flat  epithelioma  can  be  treated 
with  the  curette  followed  by  applications  of  potassium  chlorate,  or 
by  thermo-cauterization,  or  by  any  one  of  a  large  number  of  caustic 
agents. 

The  most  convenient  and  most  desirable  caustic,  which  has 
yielded  the  largest  number  of  durable  and  good  esthetic  results  in 
my  experience,  is  arsenious  acid,  employed  approximately  according 
to  the  procedure  of  Czerny  and  Trunecek.  After  the  epidermised 
surfaces  have  been  scraped,  or  freshened  or  burned  with  the  galvano- 
cautery,  they  are  painted  with  a  brush  dipped  in  a  supersaturated 
solution  of  arsenic  (arsenious  acid,  1  part;  water  and  90  per  cent, 
alcohol,  a  a  50  parts);  they  are  then  left  to  dry  and  are  covered  with 
a  pledget  of  cotton.  At  the  end  of  five  to  eight  days,  the  crust  should 
be  removed;  if  the  subjacent  surface  is  white,  it  is  practically  certain 
that  the  entire  neoplasm  has  been  destroyed;  if  it  is  mottled  with 
gray  and  red,  another  series  of  cauterizations  should  be  applied  until 
a  perfect  result  is  obtained.  This  progressive  plan  of  operating 
provides  great  security  and  spares  the  healthy  tissues  to  the  greatest 
possible  degree;  the  pain  is  rarely  very  severe  and  does  not  last 
long. 

[Many  dermatologists  prefer  the  acid  nitrate  of  mercury  to  any 
other  chemical  caustic.  The  tumor  is  vigorously  curetted,  the 
bleeding  checked  by  compression  for  a  few  minutes  and  then  the 
full  strength  Liq.  hydrarg.  nitratis  is  thoroughly  applied  by  means 
of  a  cotton  swab  for  several  minutes.  The  surface  is  then  covered 
with  a  thick  layer  of  powdered  sod.  bicarb,  firmly  pressed  down. 
Xo  other  dressing  need  be  applied.  In  ten  to  fifteen  days  the  crust 
is  shed  leaving  a  clean  granulating  surface  which  epidermises  with 
surprising  rapidity.     The  cosmetic  result  is  excellent. | 

Other  Epitheliomas. — The  cylindromas  are  treated  with  the 
curette,  with  the  bistoury,  or  with  arsenious  acid;  recurrences  are 
uncommon. 


VASCULAR  AND  CONNECTIVE-TISSUE  TUMORS         689 

New-carcinoma  has  a  gloomy  prognosis,  on  account  of  its  tendency 
to  generalization.  It  is  of  the  utmost  importance  to  intervene  early 
before  dissemination  has  occurred.  Electrolysis  constitutes  the 
treatment  of  choice;  it  sometimes  yields  unhoped-for  results.  I  am 
in  the  habit  of  inserting  the  needle  its  full  length  underneath  the  neo- 
plasm, at  numerous  points  from  4  to  5  mm.  apart  and  allowing  a 
current  of  3  to  6  milliamperes  to  pass  for  two  or  three  minutes, 
using  the  negative  pole.    Surgical  operation  is  without  advantage. 

In  secondary  carcinomas,  the  prognosis  depends  much  more 
upon  the  principal  tumor  and  its  glandular  and  visceral  generaliza- 
tion than  upon  the  cutaneous  localization.  The  latter  often  yield 
remarkably  well  to  radiotherapy. 

Summarizing,  it  may  be  stated  that  in  order  to  treat  cutaneous 
epithelioma  to  advantage,  it  is  of  importance  to  make  an  early  and 
accurate  diagnosis,  not  only  of  the  nature,  but  of  the  kind  of  tumor. 
For  this  purpose,  examination  of  tissue  by  biopsy  will  [often  be 
indispensable.  The  treatment  must  then  be  adapted  to  the  type  of 
the  neoplasm,  to  its  extent  and  its  depth,  as  well  as  to  its  seat  and 
to  the  general  condition  of  the  patient. 

VASCULAR  AND  CONNECTIVE-TISSUE  TUMORS. 

This  class  comprises  very  different  neoplasms,  all  of  which  how- 
ever originate  in  the  last  analysis  from  tissues  derived  from  that 
portion  of  the  middle  embryonic  layer  known  as  the  mesenchyma. 
Among  these  tumors,  some  have  approximately  the  structure  of 
normal  tissues,  as  in  the  case  of  fibroma,  lipoma,  myoma,  angioma, 
etc.  The  constitution  of  others  is  such  as  to  result  apparently 
from  a  local  oversupply  of  elaborated  material,  perhaps  not 
foreign  in  quality  to  the  normal  organism,  but  undoubtedly  so  in 
quantity:  to  this  order  belong  xanthoma,  urticaria  pigmentosa 
and  the  tophi  of  gout,  which  may  be  considered  as  retention 
tumors.  Finally,  in  a  third  group,  a  structure  is  found  suggestive  of 
embryonic  or  inflammatory  tissues;  in  such  cases  the  course  may 
be  benign,  as  in  botryomycoma,  or,  on  the  contrary,  of  extreme 
malignancy,  as  in  the  sarcoma. 

Fibroma. — Aside  from  fibroma  molluscum  which  has  been  men- 
tioned among  the  nevi,  there  occur  hard  dermic  or  hypodermic 
fibromata,  of  very  variable  size,  which  may  appear  at  any  age; 
they  are  sometimes  multiple  and  as  a  rule  do  not  recur  after  removal. 
They  are  formed  by  a  dense  fibrous  tissue  without  elastic  network 
and  may  undergo  fatty,  xanthomatous  or  mucous  degeneration, 
or  calcification.  Some  of  these  tumors  seemed  to  me  to  be  sarcoids 
which  had  become  fibrous;  others  might  be  regarded  as  subcutaneous 
keloids. 
44 


090 


TUMORS  OF   THE  SKIK 


Keloids  (xyfy  =  the  claw   of   a  crab)  are  histologically  simply 

hard  fibroma  s;  but  they  acquire  a  very  special  interest  through 
their  etiology,  their  appearance  and  their  clinical  course. 

Keloids  are  preferably  observed  in  children  and  in  youthful 
individuals;  their  seat  of  election  is  on  the  chest,  on  the  neck  and 
on  the  ears;  they  are  less  common  on  the  limbs.  [Negroes  are 
especially  prone  to  keloid.] 

A  distinction  has  been  erroneously  attempted  between  cicatricial 
keloids  and  spontaneous  keloids,  which  represent  a  single  variety 
of  tumors.  A  keloid  may  develop  upon  a  cicatrix  following  a  burn 
(Fig.  197),  lupus,  chancroid,  etc.,  with  the  result  that  the  scar 
assumes  a  more  than  hypertrophied  and  deformed  appearance 
(p.  336);  or  it  may  follow  a  slight  traumatism,  excoriation,  vac- 
cination, perforation  of  the  ear-lobe,  the  bite  of  a  leech,  or  the 


Keloid  df  the  neck,  on  a  cicatrix  following  a  burn. 


application  of  a  blister,  iodine  tincture,  etc. ;  it  may  also  appear  as  a 
sequel  of  furuncles,  syphilides,  or  acne  pustules.  In  the  last-named 
case,  the  post-acneic  keloids  scattered  over  the  thorax  and  the  face, 
have  nothing  in  common  with  the  affection  known  as  keloid  acne 
of  the  nape  of  the  neck  (p.  391 ).  The  relative  rarity  of  keloids  as 
sequelpe  of  wounds  in  the  late  war  is  noteworthy. 

Whatever  its  starting-point,  a  keloid  begins  as  a  circumscribed, 
intradermic  prominent  induration  which  enlarges  in  a  few  weeks  or 
months.  It  becomes  a  very  hard  tumor,  with  a  smooth,  level  or 
indented,  pinkish  or  white  surface  with  steep  or  gently  sloping 
borders,  of  globular,  oval,  or  frequently  elongated  shape;  it  often 
exceeds  the  limits  of  the  original  lesion  and  may  attain  the  size  of 
an  egg  or  form  a  band  or  elevation  thicker  than  the  finger.  Xot 
uncommonly,    the   borders   or   the   extremities   of   keloids   present 


VASCULAR  AND  CONNECTIVE-TISSUE  TUMORS         691 

fibrous  radiations  and  sometimes  bifurcated  strands,  which  suggested 
the  name  given  to  these  tumors  by  Alibert.  There  may  be  absolute 
freedom  from  pain,  or  the  patient  may  complain  of  unpleasant 
tingling  sensations. 

After  having  increased  in  size  and  extent  for  a  few  months  or 
years,  a  keloid  may  remain  stationary  or  may  undergo  spontaneous 
retrogression.  Surgical  removal  is  followed  by  recurrence  in  case 
of  recent  tumors  whose  development  has  not  been  completely 
arrested.  These  recurrences  are  common,  not  in  the  entire  extent 
of  the  surgical  cicatrix,  but  in  a  portion  of  the  scar,  in  some  of  the 
suture  points,  but  not  in  all.  Moreover,  in  case  of  acne  for  instance, 
which  becomes  keloid,  some  but  not  all  of  the  pustules  undergo  this 
development.  From  these  facts  it  may  be  concluded,  as  I  have 
pointed  out,  that  the  appearance  of  keloids  is  not  connected  with  a 
peculiarity  of  the  soil,  with  a  scrofulous  or  fibroplastic  (?)  diathesis, 
as  has  been  claimed,  but  with  a  local  infection.  I  am  inclined  to 
believe,  with  T.  C.  Fox,  J.  N.  Hyde  and  others,  that  this  infection 
is  of  tuberculous  character,  at  any  rate  in  most  cases,  so  that  the 
keloids  or  at  least  certain  keloids  are  tuberculides  or  attentuated 
tuberculoses.  Their  structure  is  that  of  a  very  dense  fibroma,  with 
mature  connective-tissue  bundles  rich  in  mast  cells  (Mantegazza, 
1897). 

In  the  treatment  of  keloids,  a  host  of  medicinal  agents  has 
been  utilized — iodine,  arsenic,  cod-liver  oil,  salicylates,  thiosina- 
mine  and  fibrolysine;  locally,  plasters,  local  douches,  scarifica- 
tion, interstitial  injections  of  creosote  oil  and  other  substances, 
electrolysis,  etc.  I  have  mentioned  the  disadvantage  of  surgical 
removal,  the  risk  of  a  larger  recurrence  with  worse  deformity. 
Radiotherapy  is  more  to  be  recommended.  A  few  sessions  will 
procure  considerable  improvement;  before  pushing  further,  the 
vitality  of  the  fibrous  tissue  must  be  aroused,  for  example,  by 
negative  electrolysis  or  by  local  injections,  or  more  practically  by 
deep  interrupted  scarifications;  after  which  the  .r-rays  may  be 
resumed  and  will  be  found  to  have  acquired  an  increased  activity. 
I  have  obtained  numerous  permanent  results  by  means  of  this 
method. 

Lipoma. — The  circumscribed  lipomas  belong  to  the  domain  of 
surgery. 

Multiple  subcutaneous  lipomas  develop  in  certain  individuals,  in 
crops  from  a  few  to  several  thousands  in  number.  Their  structure 
is  that  of  normal  adipose  tissue;  their  size  varies  from  that  of  a  pea 
to  a  small  mandarin  orange;  their  consistence  is  soft,  lobulated 
and  sometimes  pseudo-fluctuating;  their  distribution  is  often  more 
or  less  symmetrical.  The  differential  diagnosis  from  neurofibroma- 
tosis must  be  made;  this  condition  probably  represents  an  analogous 


692  TUMORS  OF  THE  SKIN 

nevic  disease.  Fibromas  are  sometimes  partly  lipomatous.  Cer- 
tain so-called  lipogenic  angiomas  have  a  tendency  to  undergo  a 
transformation  into  lipoma. 

Myxoma.  So-called  pure  myxoma,  soft  tumors  composed  of 
mucoid  connective  tissue,  are  probably  partial  elephantiasis,  as  in 
the  case  of  tumor  of  the  vulva  shown  in  Fig.  116,  in  which  the  diag- 
nosis of  myxoma  had  been  made.  These  neoplasms  are  preferably 
situated  on  the  genital  organs  and  on  the  eyelids.  Aside  from  these 
false  myxomas,  there  also  occur  myxo-sarcomas  or  sarcomas  in 
course  of  myxomatous  degeneration. 

Myoma. — The  dermatomyomas  or  cutaneous  leiomyomas — 
which  alone  will  be  discussed  in  this  place — have  been  classically 
described  by  E.  Besnier.  These  tumors,  composed  of  smooth 
muscle-fibers  forming  a  network  of  interwoven  bundles,  are  derived 
either  from  the  erector  muscles  of  the  hair-follicles,  or  from  the 
muscle  cells  of  the  vessels.  Myomas  are  rare  and  are  observed  in 
women  more  often  than  in  men.  They  may  develop  at  any  point, 
as  disseminated  or  agminated  rose-colored  elevations,  attaining  the 
dimensions  of  a  pea  or  at  most  a  hazel-nut.  They  are  frequently 
very  tender  on  pressure  and  constitute  the  majority  of  what  has 
been  described  as  painful  tubercles  of  the  skin ;  they  become  the  seat 
of  attacks  of  pain  under  the  influence  of  local  irritation  or  the  action 
of  cold. 

Calcareous  Tumors. — In  addition  to  true  osteomas,  which  are 
exceptional,  calcified  fibromas,  calcified  epitheliomas,  petrified  wens 
and  cysts,  as  well  as  phleboliths,  the  following  are  known: 

1.  The  petrous  tumors  of  Poirier,  which  are  calcified  fat-lobules 
the  size  of  a  grain  of  wheat,  occurring  on  the  inner  aspect  of  the  tibia 
in  aged  individuals. 

2.  Subcutaneous  calcareous  granulomas,  which  begin  as  a  sort  of 
cold  abscess  with  granular  or  gravelly  contents  and  may  multiply 
until  they  lead  to  death  with  systemic  symptoms.  This  affection, 
whose  lesions  closely  suggest  those  of  tuberculosis,  is  undoubtedly 
infectious. 

3.  The  subcutaneous  calcareous  concretions  of  scleroderma  (p. 
350). 

Colloid  Milium. — This  very  inappropriate  term  serves  to  desig- 
nate small, yellowish,  translucid  and  painless  tumors,  the  size  of  a  pin- 
head  to  that  of  a  pea,  which  may  be  found  scattered  or  more  or  less 
grouped  in  the  face,  on  the  neck  and  the  upper  extremities  of  adults 
of  either  sex  (p.  359).  At  first  sight  they  resemble  serous  cysts;  a 
sort  of  jelly  can  be  squeezed  out  of  them  or  they  may  be  enucleated 
with  the  curette.  Balzer  has  shown  them  to  be  made  up  of  a  colloid 
tissue;  degeneration  of  the  dermic  tissue  into  elacine  and  collacine 
has  been  demonstrated.     Milian,  who  recently  published  a  case  of 


VASCULAR  AND  CONNECTIVE-TISSUE  TUMORS        693 

colloid  milium  (1917),  interprets  the  condition  as  a  limited  prolifera- 
tion of  bundles  of  subepidermic  connective-tissue  fibers,  with 
hyaline  degeneration.  The  foci  stain  yellow  with  van  Giesen's 
stain  and  a  dull  blue  with  thionine.  With  some  attention,  it  is 
possible  to  avoid  confusion  of  colloid  milium  with  hidrocystoma, 
hidradenoma,  lupoma  or  sarcoid,  as  well  as  with  senile  colloid 
atrophy  (p.  357)  which,  moreover,  is  spread  out  in  patches  and 
diffuse.  The  galvanocautery,  carbonic  acid  snow  or  the  curette  may 
be  utilized  for  the  treatment. 

Angioma. — Hemangioma.- — The  majority  of  angiomas  are  vas- 
cular nevi,  the  lesion  consisting  of  hypertrophy  with  ectasis  of  the 
veins  and,  to  a  less  degree,  of  the  capillaries  and  the  arterioles. 

According  to  their  clinical  aspect  and  the  date  of  their  appear- 
ance a  distinction  is  made  between  several  forms: 

(a)  Flat  angiomas  or  flat  vascular  nevi,  the  port-wine  stain  of 
popular  parlance,  are  spots  of  very  variable  shape,  outline  and  dimen- 
sions, punctiform  or  in  very  extensive  patches.  Their  color  varies 
at  different  times  from  pinkish  to  bright  red  or  purple.  They  are 
especially  common  on  the  face  and  around  the  natural  orifices. 
On  the  nape  of  the  neck,  at  the  border  of  the  scalp,  they  are  encoun- 
tered in  nearly  10  per  cent,  of  all  persons.  [In  an  examination  of 
several  hundred  infants  less  than  a  week  old,  I  found  vascular  nevi 
on  the  neck  below  the  occipital  protuberance  in  one-third  of  the 
cases.  Most  of  these  become  invisible  in  the  course  of  time.]  They 
may  be  seen  on  the  mucous  membranes.  In  epileptics  and  in  feeble- 
minded persons,  patches  of  vascular  nevi  may  be  found  on  the 
entire  body  and  on  the  limbs.  [I  have  recorded  a  unique  case 
occurring  in  an  otherwise  normal  man  in  which  the  entire  integu- 
ment was  covered  with  vascular  nevi  of  the  average  size  of  a  dime, 
so  closely  placed  as  to  form  a  kind  of  network.  Histologically 
there  was  a  deficiency  of  elastic  tissue.  Dermographism  was  present.] 
These  angiomas  are,  as  a  rule,  congenital.  They  are  sometimes 
hypertrichotic. 

(b)  Tuber ovs  angiomas  are  primary  or  develop  on  the  basis  of 
the  preceding  variety.  Sometimes  they  form  merely  a  slightly 
marked  prominence,  reducible  on  pressure,  distinctly  circum- 
scribed or  with  diffuse  borders;  in  other  cases,  they  are  voluminous 
and  may  cause  more  or  less  deformity  of  the  lips,  the  nose,  the  eye- 
lids, the  ears  or  the  tongue,  up  to  lending  them  a  monstrous  appear- 
ance. The  surface  is  bright  red  and  granular  or  dark  blue  and 
lobulated,  according  to  the  depth  of  the  lesions.  Those  of  the  cheek 
and  lips  sometimes  extend  to  their  mucous  surface.  They  often 
cease  very  accurately  on  the  middle  line.  Aside  from  their  dis- 
figuring appearance,  these  tumors  may  prove  troublesome  and 
after  traumatism  may  bleed  profusely. 


()!)4  TUMORS  OF   THE  SKIS 

The  prognosis  and  the  treatment  of  these  angiomas  vary.  Some 
of  them  have  a  natural  tendency  to  a  cure,  through  lipomatous 
transformation  (lipogenic  angioma)  or  sclerotic  change;  others 
simply  persist;  still  others  are  progressive.  In  case  of  a  newborn 
infant  suffering  from  an  angioma,  its  course  should  accordingly  be 
determined  before  interfering.  In  the  first  two  cases,  delay  is  per- 
missible; in  the  presence  of  a  progressive  angioma,  prompt  measures 
are  required. 

For  a  long  time  the  only  choice  lay  between  the  following  pro- 
cedures: Compression,  usually  inefficient;  actual  cauterization  or 
applications  of  caustic  agents,  which  leave  ugly  cicatrices;  surgical 
removal,  the  method  of  choice  when  the  dimensions  and  the  seat  of 
the  angioma  permit;  scarifications,  of  advantage  in  small  flat  nevi; 
vaccination,  which  is  rarely  applicable;  and  finally  electrolysis. 
The  last-named  procedure,  the  details  of  which  have  been  well 
described  by  Brocq,  is  preferably  carried  out  with  the  positive  pole 
and  a  current  of  3  to  10  ma.  for  one  to  three  minutes;  the  number 
of  punctures  and  sessions  is  increased  until  a  satisfactory  result  is 
obtained.  [Ultraviolet  light  with  compression  often  yields  good 
results  in  the  flat  varieties.] 

At  the  present  day  radiotherapy  is  furthermore  available,  but  is 
not  always  effective  when  a  safe  dosage  is  employed.  Radium 
seems  to  me  to  possess  a  real  superiority  in  this  respect,  especially 
in  case  of  tuberous  nevi  of  moderate  depth  and  inconsiderable  size ; 
but  care  must  be  taken  to  guard  against  radium  dermatitis.  Flat 
vascular  nevi  are  advantageously  treated  with  carbonic  acid  snow, 
which  when  skilfully  handled  leaves  only  slightly  visible  cicatrices. 
Large  tuberous  angiomas  belong  to  the  domain  of  surgery. 

(c)  The  progressive  multiple  angiomas  constitute  a  clinical  form 
not  heretofore  described;  I  have  observed  several  instances  on  the 
face  or  on  the  extremities  of  young  or  adolescent  individuals.  They 
are  represented  by  at  first  subcutaneous  nodosities,  of  firm  consist- 
ence, but  reducible,  which  multiply  and  raise  up  the  skin,  giving  it 
a  slate-blue  hue;  later  on  the  skin  is  invaded  and  becomes  the  seat 
of  a  purplish  depressible  growth,  which  bleeds  readily.  Ten  or 
fifteen  of  these  tumors,  the  size  of  buckshot  to  that  of  a  large  hazel- 
nut, may  be  seen  strung  out  on  the  sole  of  the  foot  and  on  the  leg, 
or  scattered  over  the  face.  The  course  lasts  from  six  months  to  two 
or  three  years;  ultimately,  some  of  these  angiomata  spread  over 
very  extensive  surfaces,  with  diffuse  borders,  while  others  remain 
stationary  or  undergo  spontaneous  retrogression.  The  differential 
diagnosis  may  prove  difficult  from  the  pigmentary  sarcomatosis  of 
Kaposi,  from  telangiectatic  sarcoma,  or  from  nevo-careinoma,  but 
is  established  on  biopsy,  which  shows  simple  cavernous  angioma. 
It  is  of  great  importance  to  treat  these  angiomata  while  they  are 
still  small  with  electrolytic  punctures,  which  promptly  cure  them. 


VASCULAR  and  connective-tissue  tumors 


695 


(d)  Stellate  angioma  is  a  very  common  nevus,  which  often  appears 
late,  about  the  time  of  puberty  or  still  later.  It  consists  of  a  red 
and  prominent  central  point,  from  which  radiate  telangiectatic 
arborizations  resembling  spiders'  feet  (Fig.  198).  It  is  easily  con- 
trolled by  the  galvano-cautery  heated  to  a  dull  red,  or  better  by  an 
electrolytic  puncture. 


Fig.  198. — Stellate  angioma  or  vascular  nevus  araneus. 


(e)  Senile  angiomas  [in  French  "pointes  rubis,"  ruby  spots]  are 
punctiform  or  at  most  lenticular,  slightly  prominent  angiomas 
which  develop  with  great  frequency  and  in  large  numbers  on  the 
trunk  and  the  limbs  of  individuals  past  forty  years  of  age.  They 
have  been  credited  with  the  property  of  indicating  a  visceral  cancer, 
but  this  has  been  shown  to  be  erroneous.  They  may  be  considered 
as  delayed  vascular  nevi. 

(/)  The  angiokeratoma  of  Mibelli  is  observed  on  the  extremities 
of  young  individuals  with  acro-asphyxia,  suffering  from  frost-bite, 
glandular  tuberculosis,  etc.;  so  that  Leredde  classifies  it  with  the 
tuberculides.  The  lesions  present  the  appearance  of  small  spots 
of  a  bright  red  color,  grouped  or  agminated,  situated  especially  on 
the  dorsal  aspect  of  the  hands  and  fingers,  rarely  elsewhere;  their 
surface  generally  becomes  hyperkeratotic  and  verrucous.  After  a 
few  months  these  angiokeratomas  may  disappear  spontaneously. 
They  may  be  treated  like  the  senile  angiomas  with  the  galvano- 
cautery. 

In  addition  to  the  Mibelli  type,  hyperkeratoses  have  been  de- 
scribed as  occurring  on  vascular  angiomas  and  telangiectases  of  all 
kinds,  notably  on  the  scrotum  where  they  are  not  very  uncommon; 
I  have  observed  several  cases  even  upon  the  tongue. 

Lymphangioma.— These  very  rare  tumors  occur  as  the  result  of 
a  newformation  of  lymph  vessels  with  dilatation.  They  are  referable 
to  a  primary  malformation  and  must  be  considered  as  lymphatic 


G9G  TUMORS  OF  THE  SKIN 

vascular  nevi.  A  confusion  with  lymphatic  varicosities  has  caused 
much  trouble  and,  as  a  matter  of  fact,  the  distinction  between  the 
two  groups  is  not  always  easy.  In  my  opinion,  these  differences 
may  be  explained  as  follows: 

Lymphatic  varicosities,  or  lymphangiectases,  are  acquired  dilata- 
tions of  the  lymph  channels  of  the  skin  and  mucous  membranes. 
They  are  generally  a  complication  of,  or  substitute  for,  elephantiasis 
(Chapter  XVIII)  and  seem  to  be  caused  by  an  obstruction  in  a 
lymph  vessel  or  gland  as  the  result  of  tuberculosis,  syphilis,  filariasis 
and  especially  of  recurrent  erysipelas. 

Lymphatic  varicosities  are  observed  in  the  mouth,  on  the  mucosa 
of  the  lower  lip,  the  cheeks  and  the  tongue,  in  the  form  of  clear, 
translucid,  beaded  or  acuminate  pseudo-vesicles,  of  variable  number 
and  size;  they  sometimes  become  white  and  opaque;  or  sometimes 
red  or  black  through  penetration  of  blood  into  their  cavity.  They 
slightly  resemble  herpetic  vesicles,  but  are  reducible  on  pressure; 
moreover,  when  pricked  with  a  pipette,  they  furnish  an  almost 
unlimited  quantity  of  a  clear  fluid  which  is  lymph.  The  subjacent 
tissues  are  in  a  state  of  chronic  edema.  Lymphangiectases  are 
frequently  associated  with  elephantiasis  of  a  limb. 

Accordingly,  lymphatic  varicosities  may  present  themselves 
without  tumors,  as  acquired  lesions  secondary  to  a  process  causing 
lymph  stasis.  On  the  other  hand,  they  will  be  shown  to  form  also 
an  integral  part  of  the  lymphangiomas. 

Circumscribed  lymphangiomas  are  congenital  tumors  or  they 
may  appear  in  early  childhood.  They  consist  of  rose-colored 
elevations,  more  or  less  firm  to  the  touch,  conglomerated  in  patches 
and  covered  with  lymphatic  varicosities.  The  latter  are  very  com- 
monly associated  with  dilated  bloodvessels,  namely,  with  heman- 
gioma, and  this  combination  has  been  interpreted  in  a  variety  of 
ways  [and  gives  to  the  patches  a  mottled  polychromatic  appearance]. 

Lymphangiomas  are  preferably  situated  on  the  neck  and  at  the 
root  of  the  limbs;  I  have  observed  them  also  on  the  flank,  in  the 
parotid  region,  on  the  knee,  etc.  They  are  progressive,  but  slow  and 
painless,  so  that  the  patients  put  off  seeking  advice.  As  a  result  of 
interstitial  growth,  they  may  give  rise  to  monstrous  deformities. 
The  presence  of  lymphatic  varicosities  at  given  points  of  their  surface 
constitutes  their  essential  distinctive  feature. 

Lymphangioma  may  be  treated  by  extirpation,  which  is  rarely 
followed  by  recurrence  when  complete,  or  with  the  galvano-cautery, 
or  by  electrolysis;  the  latter  is  also  suitable  for  the  treatment  of 
simple  lymphangiectases.  Radiotherapy  results  in  a  well-marked 
but  transitory  improvement. 

Primary  diffuse  lymphangioma  is  identical  with  congenital  ele- 
phantiasis (Chapter  XVIII). 


VASCULAR  AND  CONNECTIVE-TISSUE  TUMORS         697 

Xanthoma. —Under  the  name  of  Xanthoma  (W.  P.  Smith)  is 
designated  the  disease  corresponding  to  Rayer's  yellow  patches  of 
the  eyelids;  the  vitiligoi'dea  of  Addison  and  Gull;  the  xanthelasma 
of  E.  Wilson,  etc. 

Until  the  last  few  years,  the  nature  of  this  disease  appeared  to  be 
very  mysterious;  as  it  could  not  be  considered  as  neoplastic,  it  was 
for  a  short  time  believed  to  be  of  infectious  origin.  Its  affinities  had 
been  recognized  on  the  one  hand  with  diabetes  or  glycosuria,  on  the 
other  with  chronic  icterus  and  diseases  of  the  liver  in  general.  The 
yellow  cast  of  the  skin  and  mucous  membranes  as  a  whole,  which 
is  noted  in  many  cases  of  xanthoma,  not  necessarily  accompanied 
by  choluria,  was  distinguished  from  icterus  and  described  as  xantho- 
chromia; it  has  theoretically  been  referred  to  xanthomatous  lesions 
of  the  biliary  passages,  which,  however,  have  never  been  demon- 
strated. Cases  of  family  or  congenital  xanthoma  were  known  to 
occur. 

Recent  contributions,  for  which  we  are  indebted  to  Pinkus  and 
Pick,  but  especially  to  Professor  A.  Chauffard  with  Grigaut  and  Guy 
Laroche,  have  shown  xanthoma  to  be  related  to  cholesterinemia. 
The  fatty  substance  which  is  abundantly  present  in  the  lesions 
and  characterizes  them,  is  not  an  ordinary  fat,  that  is,  a  fatty  acid 
glycerine  ether,  but  is  a  lipoid,  a  fatty  acid  cholesterin  ester.  The 
new  teachings  are  accordingly  as  follows: 

Cholesterin,  an  integral  constituent  of  all  body  tissues,  exists 
normally  in  the  blood  serum  in  a  ratio  which,  according  to  Grigaut, 
oscillates  between  1.20  and  1.80  per  thousand;  it  is  derived  to  a 
small  extent  from  the  food  but  mainly  from  an  internal  secretion 
of  various  tissues  and  organs,  among  which  the  suprarenal  capsules 
figure  predominantly  and  secondarily  the  corpora  lutea  of  the  ovaries. 
It  is  eliminated  through  the  bile,  either  in  its  natural  state  or  per- 
haps in  the  form  of  cholalic  acid.  Its  antihemolytic  and  antitoxic 
action  has  been  definitely  established.  Cholesterinemia  is  increased 
during  pregnancy  and  in  the  puerperal  state  as  well  as  during  men- 
struation; while  lowered  as  a  rule  at  the  onset  of  infections,  it  is 
raised  in  convalescence.  Its  highest  ratio  is  reached  in  the  course 
of  Bright's  disease  and  especially  in  icteric  conditions  due  to  reten- 
tion; its  relations  with  diabetes  are  not  constant. 

The  conclusion  has  thus  been  reached  that  when  the  cholesterin 
is  insufficiently  eliminated  it  accumulates  in  the  skin  (xanthoma) 
and  in  the  mucous  membranes,  likewise  in  the  walls  of  the  arteries 
(atheroma).  Xanthematous  deposits  have  sometimes  been  found 
on  the  endocardium,  on  the  peritoneum  and  even  in  ovarian  cysts 
(Malassez  and  de  Sinety).  The  lesions  of  xanthoma,  being  prin- 
cipally due  to  this  deposit  of  cholesterin,  may  be  considered  up  to  a 
certain  point  as  retention-tumors. 


69S 


TUMORS  OF  THE  SKIN 


Clinically,  xanthoma  presents  itself  under  four  forms: 
A.  Xanthoma  plan  nut  of  the  eyelids,  which  has  received  the  special 
name  of  xanthelasma,  is  the  most  common.  It  consists  of  straw 
yellow  or  dusky,  distinctly  outlined,  sometimes  slightly  prominent 
spots  which  are  located  more  or  less  symmetrically  on  the  most 
internal  portion  of  the  eyelids  (Fig.  L99).  Their  seat,  their  extent 
and  their  color  serve  to  distinguish  them  from  the  hidradenomas 
and  the  sebaceous  adenomas  of  this  region.  Xanthelasma  usually 
develops  insidiously  in  adults  and  aged  individuals,  somewhat 
more  frequently  in  women,  as  a  solitary  manifestation  of  xanthoma, 
often  without  apparent  disturbance  of  the  general  health.     But  I 


199.—  Xanthelasma  of  the  eyelids 


have  noted  its  rather  abrupt  onset  in  the  course  of  hypertrophic 
cirrhosis  with  icterus.  It  sometimes  becomes  associated  with  one 
of  the  following  forms: 

B.  Eruptive  xanthoma  xanthoma  tuberosum  multiplex — is  more 
uncommon;  it  may  he  met  with  at  any  age,  even  in  young  children 
(Plate  IV).  It  consists  of  papular  or  tuberous  elevations,  having 
the  dimensions  of  a  pin-head  to  those  of  a  large  bean,  of  a  golden 
yellow  color  with  a  pinkish  areola,  or  it  may  be  of  a  dark  more  or 
less  purplish  red;  in  the  latter  case,  the  yellow  hue  of  the  lesions 
can  be  demonstrated  by  means  of  vitropressure.  Their  consistence  is 
sometimes  soft,  in  other  cases  solid  or  even  keloidal.    The  eruption 


PLATE    IV 


m 


j 


./  # 


j 


i 


Eruptive  Xanthoma,  in  a  Child  of  Four  Years. 


VASCULAR  AND  CONNECTIVE-TISSUE  TUMORS         699' 

may  be  slow,  progressive,  appearing  in  successive  crops;  or  it  may 
be  sudden,  becoming  established  in  less  than  a  month ;  occasionally, 
the  yellow  papules  make  their  appearance  upon  persistent  erythe- 
mato-urticarial  spots. 

The  lesions  vary  greatly  in  numbers  in  different  cases  and  are 
sometimes  pruritic  or  painful.  They  are  somewhat  symmetrically 
arranged,  especially  on  the  elbows,  the  knees,  the  shoulders,  the 
buttocks,  the  finger-joints  and  the  scalp.  Xanthoma  may  be  said 
to  favor  high  places.  This  localization  is  perhaps  referable  to  the 
fact  that  these  regions  are  more  exposed  to  blows  and  to  friction, 
for  yellow  linear  streaks  are  not  infrequently  observed  at  the  same 
time  on  the  flexion-folds  of  the  palmar  and  plantar  regions  and  the 
fingers,  as  well  as  xanthelasma  of  the  eyelids;  in  other  words,  the 
xanthomatous  infiltration  preferably  takes  place  at  points  where 
the  skin  is  often  folded  or  bruised;  Chauffard  observed  a  patient  in 
whom  every  puncture  for  arsenic-injection  became  the  center  of  a 
xanthomatous  nodule. 

The  lesions  persist  indefinitely,  or  they  may  become  absorbed  and 
disappear.  There  is  no  reason,  however,  to  distinguish  with  [M. 
Morris]  Robinson  and  Torok  an  acute,  temporary  or  intermittent 
form,  constituting  diabetic  or  glycosuria  xanthoma.  [The  glycosuric 
form  is  however  clinically  distinguished  by  the  presence  of  a  vivid 
red  zone  on  the  sides  and  surrounding  the  base  of  each  nodule,  an 
appearance  extremely  rare  in  the  non-glycosuric  form.] 

C.  Congenital  xanthoma,  in  tumors,  manifests  itself  in  the  form 
of  prominent,  globular  or  conglomerated,  sessile  or  pedunculated 
newformations  of  a  yellow,  dusky  or  purplish  color,  soft  or  fibrous 
and  hard,  which  may  attain  the  size  of  a  mandarin  orange  or  larger. 
They  occupy  the  crest  of  the  elbows  (Fig.  200),  the  knees,  the 
shoulders,  sometimes  still  other  regions.  These  tumors  are  present 
at  the  time  of  birth,  or  make  their  appearance  in  the  course  of  the 
first  months  of  life. 

D.  Secondary  xanthomatization  has  been  seen  in  various  tumors, 
notably  in  nevi.  I  was  enabled  to  study  a  cutaneous  fibroma  which 
was  histologically  xanthomatous,  as  well  as  a  xanthomatous  rhab- 
domyoma of  the  tongue;  Pollitzer  observed  one  on  the  eyelids. 
This  cholesterin  infiltration  of  all  kinds  of  neoplasms  is  very  readily 
accounted  for  at  present. 

It  seems  advisable  in  this  connection  to  point  out  that  pseudo- 
xanthoma elasticum  (p.  358),  the  first  reported  cases  of  which  were 
confused  with  xanthoma,  is  a  cutaneous  dystrophy  of  altogether 
different  character. 

Pathological  Anatomy. — The  blood  of  xanthomatous  patients  is 
far  from  always  being  distinctly  lipemic,  with  milky  serum.  The 
highest  ratio  of  cholesterinemia  noted  by  Chauffard  (1910)  in 
patients  having  xanthelasma  is   1.90  per  thousand;    in  multiple 


700 


TUMORS  OP   THE  SKIN 


xanthoma  the  blood  has  been   found  to  contain  6.0  or  more  of 
cholesterin  per  thousand. 

The  histology  of  xanthoma  shows  that  the  lesions  are  made  up  by 
collections  in  the  cutis  of  large  connective-tissue  cells  of  very  special 
appearance,  polyhedric  or  spindle-shaped,  often  arranged  concen- 
trically around  the  vessels,  frequently  with  a  compressed  central 
nucleus  and  a  vacuolated  foamy  protoplasm;  their  vacuoles  enclose 
fatty  granules  which  will  be  discussed  presently;  these  are  the 
xanthelasmic  cells  of  Chambard,  now  known  as  xanthomatous  cells; 
in  certain  cases  a  considerable  number  of  these  are  polynuclear  and 
giant  cells.  The  xanthomatous  cells  are  arranged  in  nodules  or  in 
strands  separated  by  bands  of  connective  and  elastic  tissue.    There 


Fig.    200. — Xanthoma  in  tumors,  in  a  girl,  aged   nineteen  years.     Similar  tumors 
existed  on  the  other  elbow  and  on  both  knees,  with  xanthelasma  of  the  eyelids. 

sometimes  seems  to  be  a  fibrous  reaction  which  encloses  the  special 
constituents  and  gives  to  the  whole  a  fibromatous  consistence.  The 
epidermis  is  normal  or  loaded  with  pigment.  The  fatty  substance 
peculiar  to  xanthoma  generally  assumes  the  form  of  fine  granules  or 
round  droplets,  but  sometimes  also  that  of  crystals  in  small  rods  or 
in  hue  needles  united  in  clusters.  It  is  for  the  most  part  contained 
in  the  xanthomatous  cells,  although  some  of  it  is  also  almost  invari- 
ably found  in  the  intercellular  spaces.  It  is  soluble  in  strong 
alcohol,  in  ether  and  essential  oils;  heat  melts  it,  so  that  in  order  to 
see  it,  the  fresh  specimen  must  be  fixed  with  chromates  or  better 
with  osmic  acid  or  Flemming's  fluid,  or  with  formol;  or  cut  as 
fro/en  sections  and  mounted  in  glycerine.  It  will  be  found  that  a 
considerable  part  of  these  granules  stain  poorly  with  osmic  acid, 
take  an  orange  red  stain  with  Soudan  III  and,  as  was  first  observed 


VASCULAR  AND  CONNECTIVE-TISSUE  TUMORS         701 


by  Stoerk,  present  the  phenomenon  of  double  refraction  with 
polarized  light;  this  is  therefore  not  ordinary  glycerine-fat,  but 
rather  a  cholesterine  ether.  Other  granules  are  stained  a  deep  black 
with  osmic  acid,  are  turned  red  by  the  Soudan  reagent  and  remain 
dark  when  the  prisms  of  the  polariscope  are  crossed;  these  are 
ordinary  fats.  The  two  kinds  of  granules,  which  with  Policard  and 
Mangini  I  have  usually  found  to  exist  together  in  xanthomas,  are 
variably  distributed  in  the  lesions.  Histologically  the  difference 
between  a  simple  deposit  or  an  active  absorption  of  these  substances 
by  the  perivascular  connective-tissue  cells  cannot  be  determined. 

[In  my  opinion,  xanthoma  tuberosum  multiplex,  the  eruptive  disseminated 
form,  and  xanthoma  planum  or  xanthelasma,  the  form  that  occurs  on  the 
eyelids,  are  two  distinct  diseases.  My  studies  on  this  subject  have  been 
published  in  the  New  York  Med.  Jour.,  1898,  Jour.  Cutan.  Dis.,  1910,  xxviii, 
633,  and,  in  collaboration  with  U.  J.  Wile,  ibidem,  1912,  xxx,  235.  I  present 
here  the  principal  points  of  difference  between  the  two  diseases: 


1.  Prominent,  hard,  round  or  lobulated 
tumors. 

2.  Occurs  at  any  period  of  life  but  pref- 
erably in  early  adult  life  and  childhood. 

3.  Development  rapid,  in  a  few  weeks 
or  months. 

4.  Disappears  after  months  or  years, 
or  undergoes  fibrous  changes  and  persists 
indefinitely. 

5.  Extremely  rare. 

6.  Distribution  general  with  the  neigh- 
borhood of  the  large  articulations  as  seat 
of  predilection.  (Under  the  tense  epi- 
thelium of  the  palms  the  tumors  may  be 
spread  out  in  stria?  along  the  normal  folds.) 

7.  Histologically,  xanthoma  is  an  irrita- 
tive connective-tissue-cell  hyperplasia, 
due  to  the  presence  of  cholesterol  fatty- 
acid  esters  derived  from  the  blood.  The 
process  begins  in  the  cells  of  the  vascular 
adventitia,  which  take  up  the  extruded 
fatty  particles,  increase  in  size  and  pro- 
liferate, sometimes  becoming  multinu- 
cleated. These  cell  masses  in  turn 
commonly  act  as  stimulants  to  the  pro- 
duction of  fibroblasts,  resulting,  in  old 
xanthomas,  in  the  development  of  fibro- 
mas  which  have  erroneously  been  inter- 
preted as  the  primary  tumor,  "xantho- 
fibroma." Xanthoma  connotes  a  systemic 
disease,  a  disturbance  of  metabolism.] 


Xanthelasma. 

1.  Flat,  soft,  indistinguishable  on  pal- 
pation, or  if  at  all  prominent,  feels  like  a 
bag  of  fat. 

2.  Practically  unknown  before  middle 
age. 

3.  Development  slow,  extending  over 
years. 

4.  Persists  unchanged  through  life; 
never  undergoes  fibrosis. 

5.  Quite  common. 

6.  Limited  to  face  and  neck,  the  region 
of  voluntary  cutaneous  muscles. 


7.  No  signs  of  connective  tissue  or  other 
inflammatory  changes.  It  occurs  only 
when  there  are  striated  muscle  fibers  in 
the  skin,  that  is,  the  face  and  neck 
(platysma),  but  similar  degenerations 
have  been  observed  in  the  tongue,  the 
uvula  and  in  congenital  myomata  and  are 
reproduced  to  some  extent  in  the  waxy 
degeneration  of  muscles  after  typhoid, 
etc.  The  so-called  xanthoma  cells  of 
xanthelasma  are  cross-sections  or  frag- 
ments of  muscle  fibers  of  the  orbicularis 
palpebrarum  which  have  undergone  a 
peculiar  cholesterol  fatty  degeneration 
with  proliferation  of  sarcolemma  nuclei. 
Xantho-myoma  does  not  occur ;  so  far  from 
a  tumor  or  increase  of  the  muscle  tissue 
there  is,  on  the  contrary,  a  disappearance 
of  muscle  fibers.  In  long-standing  xanthe- 
lasma there  is  scarcely  anything  left  of 
the  original  muscle  in  the  areas  affected. 
Xanthelasma  is  independent  of  any 
known  general  disorder.  It  belongs  with 
the  cutaneous  degenerations.] 


702  TUMORS  OF  THE  SKIN 

Treatment. — As  a  rule,  xanthoma  shows  a  tendency  to  persist 
and  increase.  The  undesirable  spots  of  xanthelasma  and  even  the 
xanthomatous  papules  can  be  made  to  disappear,  however,  almost 
without  cicatrices,  by  very  careful  cauterization  with  the  galvano- 
cautery,  heated  to  a  dull  red.  The  classical  medication  with  tur- 
pentine in  capsules,  which  has  long  been  followed,  seems  advantage- 
ous. At  the  present  day,  however,  the  treatment  must  obviously 
be  based  upon  the  hypocholesterin  diet,  recommended  by  Chauft'ard, 
consisting  of  roasted  and  broiled  meats,  green  vegetables,  skimmed 
milk,  fruits  and  sugar. 

Tophi  of  Gout. — If  the  modern  interpretation  of  xanthoma  is 
correct,  this  disease  presents  great  analogies  with  gout.  The  uric 
acid  which  circulates  in  excess  in  the  blood  in  the  last-named 
dyscrasia,  is  deposited  not  only  in  the  joints  and  the  peri-articular 
tissues  and  sometimes  in  the  viscera,  but  frequently  also  in  the  skin. 
The  urates  deposited  in  the  cutis  and  the  cellular  tissue  are  known 
as  tophi.  According  to  Garrod  and  Charcot,  who  made  a  special 
study  of  the  subject,  tophi  are  found  in  nearly  one-half  of  all  gouty 
patients  (lb  times  in  37  cases). 

Their  seat  of  election  is  on  the  external  ears,  in  the  groove  or  on 
the  sharp  border  of  the  helix,  where  these  concretions,  from  one  or 
two  to  about  ten  in  number,  constitute  small  tumors  the  size  of  a 
millet-seed  to  a  pea.  Their  color  is  normal  or  purplish,  with  an 
opaque  white  hue  shining  through  it.  Tophi  have  occasionally 
been  observed  in  various  other  regions;  on  the  ala?  or  on  the  bridge 
of  the  nose,  on  the  scalp,  on  the  eyelids,  etc. 

Their  other  common  seat  is  in  the  vicinity  of  gouty  joints,  over 
the  olecranon  or  the  prepatellar  bursa  for  example,  or  around  the 
joints  of  the  fingers  and  toes.  These  tophic  concretions  are  sub- 
cutaneous or  intradermic;  at  first  small  and  multiple,  they  tend  to 
become  agglomerated  and  spread  out.  Soft  at  first,  they  subse- 
quently become  extremely  hard. 

Tophi  make  their  appearance  as  a  rule  after  attacks  of  gout, 
causing  slight  inconvenience  and  sometimes  disappearing  spon- 
taneously ;  in  other  cases,  abscesses  develop,  or  still  more  frequently 
the  skin  becomes  stretched,  opens  without  suppuration  and  permits 
the  escape  of  a  chalky  substance  chiefly  composed  of  sodium  urate. 
Under  the  microscope  it  appears  as  circular  crystals,  soluble  in  hot 
water,  which  on  treatment  with  acetic  acid  yield  uric  acid  crystals; 
with  nitric  acid  and  ammonia,  the  murexide  reaction  is  obtained. 

In  contradistinction  to  lime  concretions,  urate  concrements  are 
transparent  to  the  .r-rays.  It  has  been  suggested  to  treat  them  by 
means  of  lithium  ionization.  The  simplest  way  to  get  rid  of  tophi 
on  the  ears  is  extirpation  with  the  curette,  under  local  anesthesia. 


VASCULAR  AND  CONNECTIVE-TISSUE  TUMORS 


703 


Urticaria  Pigmentosa.— The  name  given  to  this  affection  by 
Nettleship  is  not  a  good  one,  in  so  far  as  it  leads  to  confusion  with 
pigmented  urticaria  (Chapter  II). 

Urticaria  pigmentosa  (xanthelasmoidea  of  T.  C.  Fox)  is  not  a 
variety  of  urticaria,  but  a  chronic  skin  disease  which  histologically 
is  ranged  with  the  retention  tumors. 


-Urticaria  pigmentosa  in  the 
resting  state. 


Fig.  202. — The  same  urticaria  pigmen- 
tosa in  the  urticarial  state,  after  irrita- 
tion by  energetic  rubbing. 


It  is  characterized  by  spots  or  not  very  prominent  elevations,  from 
a  pin-head  to  a  fingernail  in  size,  of  a  dusky  or  tawny  color;  these  are 
distributed  over  the  integument  in  variable  number,  from  a  dozen 
or  so  to  several  hundreds,  situated  especially  on  the  trunk  and  on  the 
limbs,  but  sometimes  also  on  the  head  and  the  extremities. 

The  pathognomonic  sign  of  urticaria  pigmentosa  consists  in  the 
inherent  property  of  these  spots  or  elevations  to  become  congested, 
swollen,  firm  and  distinctly  urticarial  under  the  influence  of  active 
scratching  or  pressure  with  a  blunt  instrument  (Figs.  201  and  202). 

This  sign  by  itself  alone  would  suffice  to  differentiate  these  lesions 
from  those  of  lichen  planus,  psoriasis,  syphilides  or  tuberculides,,  or 
from  simple  macules  which  they  sometimes  closely  resemble  * 


70-4  TUMORS  OF  THE  SKIN 

The  usual  teaching  is  to  the  effect  that  urticaria  pigmentosa  begins 
a  short  time  after  birth,  rarely  after  the  first  year;  that  it  disappears 
at  the  end  of  eight  or  ten  years  through  progressive  obliteration  and 
would  accordingly  be  very  rare  in  adults.  This  is  often  correct.  I 
have  shown,  however,  before  the  French  Dermatological  Society 
in  1905,  that  this  affection  may  last  indefinitely;  that  its  appear- 
ance may  be  noted  at  puberty  or  even  at  a  mature  age;  that  it  is 
sometimes  familial.  The  eruption  in  some  cases  is  subject  to  con- 
gestive attacks  with  pruritus,  spontaneous  or  in  connection  with 
sweating;  in  other  cases,  it  remains  sluggish  and  latent,  so  that  its 
existence  may  be  overlooked  on  superficial  examination.  The  exist- 
ence of  dermographism  has  been  reported  in  these  patients;  this  may 
be  a  mere  coincidence  and  at  all  events  is  not  common. 

The  histology  of  the  lesions  shows  in  the  cutis  an  abundant 
infiltration  of  mast-cells,  staining  a  purplish  red  with  polychrome 
blue;  these  cells  are  spindle-shaped,  oval  or  polygonal  when  ac- 
cumulated in  masses.  Pigment  is  found  in  the  basal  layer  of  the 
epidermis  and  in  the  papillary  body. 

The  etiology  is  unknown.  Cutaneous  irritation,  nervousness  and 
emotional  disturbances  have  been  held  responsible.  It  seems  to 
me  that  auto-intoxications  of  digestive  origin  or  certain  disturb- 
ances of  the  hepatic  function  may  play  a  role.  Investigations 
aiming  at  the  separation  of  the  complex  of  hepatic  insufficiency  and 
biliary  retention  may  help  to  elucidate  this  problem,  as  in  the  case 
of  xanthoma.  If  I  am  mistaken  in  this  hypothesis,  urticaria  pig- 
mentosa will  have  to  be  considered  as  related  to  the  nevi. 
•  All  treatment  hitherto  attempted,  including  hot  and  cold  hydro- 
therapy, radiotherapy,  phototherapy,  electrolysis,  etc.,  has  on  the 
whole  proved  useless.  All  that  can  be  done  is  to  prescribe  a  correct 
hygiene. 

Botryomycoma  [Granuloma  pyogenicum]. — This  designation  is 
applied  to  certain  benign  tumors,  or  rather  persistent  inflam- 
matory products  which  assume  the  behavior  of  tumors,  possessing 
very  peculiar  morphological  and  histological  features. 

There  is  sometimes  seen  on  the  hands  or  on  the  fingers,  or  on  the 
sole  of  the  feet,  a  small  soft  prominent  elevation,  bright  red  in  color, 
smooth  or  resembling  a  raspberry,  the  size  of  a  pea  to  that  of  a 
large  hazel-nut;  its  essential  feature  consists  in  its  being  strangulated 
at  the  base,  or  even  plainly  pedunculated,  as  may  be  verified  in 
doubtful  cases  with  the  help  of  a  stylet  or  a  hook.  Less  commonly, 
similar  growths  have  been  observed  on  the  leg,  the  forehead,  the 
lips  and  elsewhere.  As  a  rule  the  patient  will  remember  some 
puncture  or  wound  which  he  has  sustained  at  this  point  and  which 
has  been  suppurating  for  a  few  weeks  or  months  previously.    He  will 


VASCULAR  AND  CONNECTIVE-TISSUE  TUMORS 


705 


generally  admit  having  repeatedly  cauterized  or  irritated  it  in  various 
ways.    These  tumors  may  persist  for  years  (Fig.  203). 

On  histological  examination  they  are  found  to  consist  of  inflam- 
matory or  embryonic  connective  tissue  with  large  and  abundant 
newly  formed  capillaries;  briefly,  showing  the  structure  of  chronic 
"proud  flesh"  [granulation  tissue].  The  epidermis  is  missing  on 
their  surface  and  usually  stops  at  the  level  of  the  pedicle  or  slightly 
above  it. 


Fig.  203. — Botryomycoma  of  seven  months'  standing  irritated  by  traumatism  and 
applications  of  nitric  acid. 


The  interest  aroused  by  these  peculiar  small  products  and  the 
inappropriate  name  they  bear  are  due  to  the  statement  of  Poncet 
and  Dor,  in  1897,  to  the  effect  that  these  inflammatory  growths 
contained  mulberry-shaped  hyaline  globules,  sometimes  visible  to 
the  naked  eye,  similar  to  those  which  had  been  described  by  Bol- 
linger under  the  name  of  botryomyces  in  the  fungoid  growths  follow- 
ing castration  in  horses;  it  is  now  known  that  this  appearance  is 
not  due  to  a  parasite,  but  to  cellular  dege  nerations  of  pycnotic  type. 

Moreover,  the  coccus  growing  in  yellow  cultures  which  can  be 
isolated  from  human  as  well  as  animal  botryomycoses  possesses  no 
special  features  and  is  not  entitled  to  the  name  of  botryococcus 
ascoformans,  applied  to  it  by  Kitt;  it  is  nothing  more  nor  less  than 
the  Staphylococcus  aureus.  It  would  therefore  be  justifiable  to 
group  the  tumors  caused  by  it  under  the  heading  of  pyococcal 
dermatoses. 

[The  name  Botryomycoma,  based  on  an  erroneous  pathogenesis, 
is  obviously  objectionable.     The  term  granuloma  pyogenicum  ,  pro- 
posed by  Hartzell,  is  to  be  preferred.] 
45 


706  TV  MORS  OF   THE  SKIN 

The  treatment  of  these  newformations  consists  in  their  complete 
ablation  [followed  by  cauterization];  there  is  no  danger  of  recurrence. 
[Nevertheless,  unless  they  are  thoroughly  cauterized  they  often 
recur.] 

SARCOMA. 

Sarcomas  are  connective-tissue  tumors  of  embryonic  structure, 
usually  possessing  great  malignancy. 

On  the  skin  are  observed:  primary  idiopathic  .sarcoma,  which 
alone  will  be  considered  here;  and  secondary  metastatic  sarcoma, 
derived  from  the  generalization  of  sarcomatous  tumors  of  the  viscera, 
the  glands  or  the  bones. 

The  primary  cutaneous  sarcomata  belong  to  different  varieties. 
From  the  histological  point  of  view,  a  distinction  can  be  made 
between  the  following: 

1.  Round-cell  .sarcoma,  which  consists  either  of  small  round  cells 
or  of  large  round  cells. 

2.  Spindle-cell  sarcoma,  with  spindle-shaped  or  fasciculated  cells. 

3.  Atypical  sarcoma  with  polymorphous  cells  which  were  errone- 
ously described  by  me  in  former  publications  and  in  the  first 
edition  of  this  book,  under  the  name  of  lymphosarcoma. 

The  so-called  pigmented  sarcoma  is  a  nevocarcinoma  (p.  682) 
which  surgeons  persist  in  calling  melanotic  .sarcoma.  The  multiple 
idiopathic  pigmented  sarcoma  of  Kaposi  (1872)  is  a  separate  affec- 
tion, probably  of  infectious  origin. 

A.  Typical  Sarcoma. — These  tumors  are  characterized  by  their 
being  composed  almost  exclusively  of  embryonic  connective-tissue 
cells,  all  of  the  same  type,  round  or  spindle-shaped  in  different  cases, 
not  contained  in  an  adenoid  network  and  whose  bloodvessels  are 
lacunar,  in  the  sense  that  their  walls  are  formed  by  the  tumor 
constituents  themselves. 

This  neoplasm  of  relatively  homogeneous  structure  invades  the 
neighboring  tissues  by  substitution,  not  by  interstitial  infiltration; 
metastases  occur  by  way  of  the  bloodvessels  rather  than  by  the 
lymphatic  route.  These  features  are  not  invariable,  however,  for 
any  sarcoma  may  present  some  rare  dissimilar  constituents,  chorio- 
plaxes,  giant  cells,  etc.,  as  well  as  points  of  interstitial  infiltration 
on  sonic  of  its  borders. 

Spindle-cell  or  fascicular  .sarcoma,  with  large  or  small  fusiform 
cells  arranged  in  interlacing  bundles,  presents  itself  clinically  under 
the  aspect  of  a  hard,  indistinctly  outlined  dermo-hypodermic  tumor, 
of  a  dark  red  or  purplish  color,  interspersed  with  telangiectases; 
it  grows  slowly  and  finally  becomes  superficially  ulcerated;  it  has 
only  a  slight  tendency  toward  glandular  or  visceral  metastases,  but 
usually  recurs  promptly  after  surgical  removal, 


SARCOMA 


707 


Round-cell  sarcoma,  with  small  or  large  round  cells,  develops 
more  rapidly  and  usually  becomes  generalized.  The  initial  tumor 
may  be  situated  at  any  point  of  the  body,  except  on  the  extremities ; 
whether  operated  upon  or  not,  it  becomes  associated  after  a  few 
months  with  secondary  tumors  in  progressive  number,  from  about 
twenty  to  several  hundreds,  first  in  the  same  region,  then  scattered 
on  the  trunk,  the  root  of  the  limbs  and  the  head  with  relative 
freedom  of  the  hands  and  feet.  Some  of  the  tumors  are  at  first 
hypodermic  and  movable  under  the  skin,  which  presents  a  lavender 
hue  and  an  orange-peel  appearance,  before  it  becomes  invaded. 
Other  tumors  are  dermic,  pink,  dark  red,  then  purplish,  the  size  of 
a  pea  or  a  hazel-nut  to  that  of  a  mandarin  orange,  of  hard  or  soft 


Fig.  204. — Generalized  sarcomatosis.     Woman,  aged  fifty-two  years;  onset  in  the 
pectoral  region  three  years  before;  death  in  the  course  of  the  fourth  year. 


consistence;  after  a  certain  time,  they  undergo  ulceration  through 
necrosis;  followed  by  fever,  diarrhea,  hemorrhages,  finally  death 
due  to  cachexia,  after  a  total  duration  of  one  to  four  years.  The 
glands  are  found  to  be  intact,  but  metastases  are  sometimes  found 
in  the  lungs,  liver  and  spleen.  The  blood  at  the  period  of  the  ulcer- 
ations presents  a  leukocytosis  of  20,000  to  40,000,  with  predominance 
of  the  polynuclears.  This  pathological  type,  known  as  generalized 
sarcomatosis  (Fig.  204)  is  observed  especially  in  patients  between 
forty-five  and  sixty  years  of  age. 

Angiosarcoma  is  a  malignant  tumor,  frequently  multiple,  de- 
veloping slowly  in  adults,  more  rapidly  in  children,  consisting  of 
fascicular  sarcomatous  tissue  with  telangiectases;  opinions  differ 


708  TUMORS  OF  THE  SKIN 

as  to  its  being  an  angioplastic  sarcoma  or  an  angioma  which  has 
become  sarcomatous.  These  tumors  have  been  observed  especially 
on  the  scalp,  in  the  upper  part  of  the  face  and  on  the  upper  part  of 
the  trunk. 

Sarcomas  with  myeloplaxes  are  extremely  rare  and  seem  to  be 
secondary  to  tumors  of  the  bones. 

Parini  is  said  To  have  observed  a  case  primary  in  the  skin. 

B.  Atypical  Sarcoma  with  Polymorphous  Cells. — I  have  repeatedly 
drawn  attention  to  this  form  of  sarcoma,  under  the  name  of  "lympho- 
sarcoma:" this  denomination  has  the  disadvantage  of  creating  con- 
fusion by  suggesting  the  identity  of  this  form  with  the  glandular 
lymphosarcoma  of  Kundrat-Paltauf  (p.  653);  since  this  identity 
seems  to  me  in  no  way  established,  nor  even  probable,  I  have  adopted 
the  denomination  given  above,  in  my  report  of  an  illustrative  case 
(Annates  de  Dermatologie,  April,  1911,  p.  220). 

This  form  of  sarcoma  is  characterized  histologically  by  a  very 
special,  alveolar  or  areolar  structure  on  account  of  which  it  has 
received  from  the  old  anatomo-pathologists  the  names  of  alveolar 
sarcoma  (Billroth)  and  reticular  carcinoma  (Cornil  and  Ranvier). 
The  more  or  less  dense  network  is  sometimes  adenoid,  composed  of 
fine  fibrils,  while  in  other  cases  it  consists  of  larger  fibrous  strands, 
provided  with  connective-tissue  cells ;  or  again  it  may  be  embryonic 
and  myxomatous;  or  it  may  vary  in  appearance  at  different  points 
of  the  same  tumor.  The  constituents  enclosed  in  its  meshes  are  con- 
nective-tissue cells  of  embryonic  or  fetal  type  and  very  polymor- 
phous, being  small  and  round,  or  rather  large  and  round,  or  fusiform 
and  stellate,  sometimes  multinuclear;  among  them  plasmocytes  are 
sometimes  met  with,  but  very  few  or  no  lymphoid  or  myeloid  con- 
stituents; the  polynuclears  are  numerous  in  ulcerated  tumors. 
The  bloodvessels,  instead  of  being  purely  lacunar  as  in  the  other 
sarcomata,  have  distinct  walls,  but  without  elastic  fibers.  The 
boundaries  of  the  tumor  are  less  distinctly  outlined  than  those  of  the 
other  sarcomas. 

Clinically,  these  polymorphous  alveolar  sarcomas  are,  after  the 
epitheliomas,  the  most  common  primary  malignant  tumors  of  the 
skin.  They  are  observed  in  both  sexes,  in  adolescence  or  adult  life, 
preferably  in  the  vicinity  of  the  natural  orifices. 

The  process  begins  as  a  small  pink  intradermic  nodule,  of  firm 
consistence;  this  develops  in  breadth  rather  than  in  thickness, 
finally  giving  rise  to  a  large,  hard,  globular  or  spreading  tumor, 
which  for  a  long  time  remains  solitary,  more  or  lesss  rapidly  under- 
going erosion  or  ulceration.  A  large  and  hard,  sometimes  also 
ulcerated  glandular  enlargement  is  noted  at  an  early  stage,  which 
does  not  occur  in  any  other  form  of  sarcoma.  Secondary  nodules 
finally  develop  in  the  vicinity;  generalization  takes  place  by  the 
lymphatic  route,  as  in  the  case  of  the  epitheliomas. 


SARCOMA  709 

This  variety  is  thus  seen  to  differ  in  many  respects  from  the  so- 
called  typical  sarcomas. 

C.  Multiple  Hemorrhagic  Sarcomatosis. — This  designation  is 
applied  to  a  disease  which  is  clearly  differentiated  by  its  clinical 
behavior  and  by  the  structure  of  its  lesions;  their  character,  how- 
ever, is  probably  very  different  from  that  of  the  sarcomas.  It  is 
the  idiopathic  pigmented  sarcoma  of  Kaposi. 

It  begins  at  the  extremities,  or  as  a  solitary  tumor  at  any  point, 
sometimes  as  the  sequel  of  a  local  traumatism;  lesions  promptly 
develop  on  the  feet  and  hands,  nearly  always  symmetrically. 

There  are  either  very  hard  edematous  swellings,  livid  or  slate- 
colored,  in  spots  or  in  patches,  often  imperfectly  outlined;  or 
small  tumors,  miliary  or  pea-sized,  at  first  intradermic,  then  pro- 
tuberant or  even  pedunculated,  often  agminated.  These  tumors,  in 
very  variable  number,  appear  on  the  infiltrated  surfaces  as  well  as 
on  the  healthy  skin;  they  vary  in  hue  from  a  dark  rose  color  to 
purplish  and  black;  hemorrhagic  spots  are  likewise  noted.  The 
lesions  progress  from  the  periphery  to  the  center;  after  the  legs  and 
the  forearms,  the  thighs,  the  genital  organs,  the  mouth,  the  back  and 
finally  the  internal  organs  are  invaded.  Movements  are  consider- 
ably impaired,  but  the  pain  is  moderate;  the  tumors  and  infiltra- 
tions never  assume  a  marked  development,  they  have  only  a  slight 
tendency  to  ulcerate  and  are  even  capable  of  undergoing  sponta- 
neous absorption.  The  glands  usually  remain  free.  The  general 
health  may  be  good  until  the  terminal  stage  is  reached. 

Kaposi's  sarcomatosis  attacks  especially  men  from  forty  to  sixty 
years,  particularly  laborers,  but  sometimes  children.  It  lasts  from 
two  to  ten  years  and  leads  to  death  through  generalization,  with 
fever,  cachexia,  hemorrhages,  etc.  It  is  not  rare  in  Poland,  Russia, 
Austria  and  Italy,  but  altogether  exceptional  in  France.  [In 
America  it  occurs  almost  exclusively  among  Jews,  possibly  because 
the  great  majority  of  our  Russian,  Austrian  and  Polish  immigrants 
belong  to  this  race.] 

Histologically,  the  lesions  consist  of  a  newformation  of  dilated 
capillary  bloodvessels,  with  lymphatic  dilatations  and  collections  of 
round  and  fusiform  cells  arranged  parallel  with  the  vessels  in  vari- 
able proportions.  The  pigment  is  hemosiderin,  of  hemorrhagic 
origin. 

There  is  a  tendency  to  question  the  neoplastic  character  of  this 
disease  and  to  consider  it  as  infectious;  its  pathogenic  agent  is 
unknown;  it  is  not  auto-inoculable  and  does  not  seem  to  be  con- 
tagious. 

Diagnosis  of  the  Sarcomas. — As  many  sarcomas  are  hypodermic 
at  the  onset,  their  differential  diagnosis  must  be  made  from  all  the 
nodosities  (Chapter  XIV),  the  gummas  and  especially  the  sarcoids, 


710  TUMORS  OF  THE  SKIN 

and  furthermore  from  the  benign  subcutaneous  or  cutaneous  tumors, 
and  from  adenitis  or  certain  subacute  or  chronic  phlegmons. 

Secondary  carcinoma  of  the  skin,  nevo-carcinoma,  cylindroma, 
mycosis  fungoides,  the  leukemic  tumors  can  sometimes  be  differ- 
entiated only  with  considerable  difficulty. 

The  polymorpho-cellular  sarcoma  may  closely  resemble  epithe- 
lioma, certain  forms  of  cutaneous  tuberculosis  and  even  syphilitic 
chancre. 

The  hemorrhagic  sarcoma  of  Kaposi  must  be  distinguished  at  the 
onset  from  nevo-carcinoma,  from  botryomycoma,  from  scleroderma; 
and  in  the  course  of  its  development,  from  the  tertiary  syphilides, 
from  lupus  and  more  particularly  from  leprosy,  certain  cases  of 
which  have  very  closely  simulated  it  in  my  experience. 

In  all  doubtful  cases,  biopsy  and  histological  examination  as  well 
as  cytological  analysis  of  the  blood  will  be  required  for  the  confirma- 
tion of  the  diagnosis;  it  is  advisable  to  resort  to  these  procedures 
even  when  the  clinical  features  and  the  course  seem  more  or  less 
convincing  by  themselves. 

Treatment. — Surgical  removal  is  to  be  recommended  only  at  the 
very  beginning,  before  generalization  has  had  time  to  occur  and  must 
be  as  early  and  extensive  as  possible.  In  its  absence,  or  directly 
afterward  and  as  complementary  measures,  the  following  treatment 
should  be  employed: 

Arsenic  has  at  all  times  been  universally  advocated  against  every 
form  of  sarcoma;  it  is  given  in  large  doses  and  particularly  in  hypo- 
dermic injections  of  potassium  or  sodium  arsenite.  At  the  present 
day,  intravenous  injections  of  arsenobenzols  are  of  course  entitled 
to  a  preference.  It  has  seemed  to  me  as  to  many  others,  that  the 
progress  of  sarcoma  is  delayed  for  some  time  under  the  influence  of 
arsenic.    [On  the  use  of  arsenic  in  chronic  diseases  see  my  note  p.  661 .] 

The  other  treatment  which  has  been  found  of  value,  at  least  in  a 
certain  number  of  cases,  is  radiotherapy;  it  has  not  been  demon- 
strated that  radium  is  more  efficient,  except  in  certain  regions  not 
readily  accessible  to  the  .r-ray  tube.  The  .r-rays  are  certainly 
capable  of  diminishing  the  size  and  even  of  causing  the  absorption 
of  sarcomas,  but  this  is  far  from  saying  that  they  can  effect  a  com- 
plete cure.  Of  course,  large  doses  are  administered  in  such  cases; 
opinions  differ  concerning  the  necessary  degree  of  filtration  and  the 
general  plan  of  the  treatment  which  notwithstanding  the  gravity 
of  the  condition  must  nevertheless  be  cautiously  conducted.  It 
goes  without  saying  that  these  two  therapeutic  procedures  may  and 
should  be  employed  concurrently. 

Unfortunately,  the  physician  is  often  consulted  too  late,  when 
generalization  is  under  way  and  all  treatment  has  become  powerless; 
so  that  sarcoma  still  has  an  extremely  serious  prognosis. 


APPENDIX. 


THERAPEUTIC  NOTES. 

On  undertaking  the  treatment  of  a  dermatosis,  as  with  any  other 
pathological  condition,  it  is  necessary  to  look  into  the  therapeutic 
indications  to  begin  with,  as  soon  as  a  positive  diagnosis  has  been 
made.  What  is  to  be  done?  What  kind  of  medication  may  prove 
beneficial?  By  what  kind  of  intervention  may  one  hope  to  cure, 
that  is,  to  restore  the  organism,  as  far  as  possible,  to  a  normal 
condition? 

The  choice  of  the  method  must  therefore  necessarily  precede  the 
choice  of  the  remedy.  Nothing  could  be  more  unreasonable  than 
to  take  up  a  formulary  and  blindly  order  some  medicinal  compound, 
without  knowing  the  mechanism  of  its  action  and  consequently  the 
effects  which  it  may  produce. 

The  reason  for  the  selection  of  a  given  remedy  is  sometimes 
supplied  by  the  cause  of  the  disease,  when  this  is  known  and  can  be 
so  acted  upon  as  to  remove  it  (examples :  scabies,  syphilis) ;  in  other 
cases  it  is  the  pathogenic  mechanism  which  can  be  influenced;  but 
more  frequently,  at  least  in  dermatological  practice,  the  lesions 
themselves  dictate  the  mode  of  intervention,  according  to  their 
nature,  morphology  and  degree.  It  is  really  of  minor  importance 
from  the  therapeutic  point  of  view,  if  an  acute  eczematiform  derma- 
titis, for  instance,  be  due  to  a  physical  or  mechanical  agent,  or  to 
this  or  that  chemical  substance;  what  has  to  be  checked  is  the 
inflammation,  the  oozing,  itching,  etc.;  what  has  to  be  foreseen,  in 
order  to  prevent  it,  if  possible,  is  the  superadded  infection;  what 
must  be  aimed  at  is  not  to  inhibit  but  on  the  contrary  to  favor 
cellular  regeneration. 

At  the  end  of  each  section  of  this  book,  I  have  taken  pains  to 
indicate  briefly  the  kind  of  medication  adapted  to  the  cutaneous 
affection  or  to  the  disease  under  consideration. 

Here  I  propose  to  enter  into  greater  detail  concerning  some  of  the 
modes  of  treatment. 

It  would  be  a  waste  of  time,  at  the  present  day,  to  compare  the 
relative  value  of  internal  and  external  treatment  in  dermatology. 
Each  has  its  own  domain,  determined  by  the  cause  and  nature  of  the 


712  APPENDIX 

pathological  process  on  the  one  hand  and  by  the  general  condition  of 
the  patient  on  the  other.  Xo  general  remarks  of  practical  value  in 
this  connection  are  possible. 

I  shall  not  dwell  upon  the  different  measures  which  constitute 
the  armamentarium  of  the  general  treatment  of  skin  diseases;  these 
belong  to  the  domain  of  general  medicine.  It  goes  without  saying 
that  the  general  hygiene,  the  cutaneous  hygiene,  the  diet  (to  which  a 
paragraph  will  be  devoted  at  the  end  of  this  chapter)  and  even  the 
emotional  hygiene — all  of  which  play  a  part  in  the  etiology  of  certain 
cutaneous  affections,  require  great  attention  and  must  be  corrected 
in  a  considerable  number  of  cases. 

In  the  course  of  this  work,  I  have  repeatedly  pointed  out  the 
advantages  offered  by  hydrotherapy,  climatotherapy,  heliotherapy, 
watering-places,  the  various  groups  of  sera,  by  opotherapy,  vaccino- 
therapy, ferments  and  yeasts,  etc. 

In  regard  to  internal  pharmaceutic  remedies,  I  have  had  occasion 
to  supply  some  information  concerning  those  of  capital  importance 
or  most  frequently  employed  in  dermato-therapy  (arsenic,  arseno- 
benzols,  mercury,  etc.).  A  lengthy  discussion  of  this  subject  would 
take  me  beyond  the  limits  assigned  to  this  book.  I  restrict  myself 
to  the  reminder  that  the  medicinal  agents  most  frequently  required 
include  the  following:  the  laxatives,  quinine,  cod-liver  oil,  calcium 
salts,  phosphoric  acid,  phosphates  and  glycerophosphates,  iodides 
and  iodine-tannin  preparations,  chaulmoogra  oil,  sulphur  and  its 
compounds,  iron,  valerian,  etc. 

The  local  treatment  likewise  comprises  various  procedures  or 
modes  of  action;  their  indications  have  been  mentioned,  but  they 
cannot  here  be  described  in  detail. 

They  can  be  classified  under  four  headings,  as  follows: 

1.  Surgical  extirpation,  applicable  especially  to  a  large  number  of 
tumors,  certain  cases  of  lupus,  etc. 

2.  Dermatological  operations,  curettage,  scarifications,  epilation, 
and  cauterization;  this  technic  and  the  results  which  can  be  obtained 
are  admirably  described  in  the  writings  of  my  colleague  and  friend 
Dr.  Brocq,  notably  in  his  Traite  de  Dermatologie  pratique  (O.  Doin, 
Paris,  1908,  Vol.  I),  to  which  the  reader  is  referred. 

3.  The  different  forms  of  physico-therapy  (electrolysis,  static 
electricity,  Franklinization,  high  frequency,  radiotherapy  with 
.r-rays,  radium  and  radio-active  substances,  phototherapy,  light- 
baths,  Bier's  method,  treatment  with  hot-air  or  carbonic  acid  snow, 
massage,  etc.).  These  methods  are  described  in  special  text-books 
and  it  would  be  futile  to  offer  a  necessarily  very  incomplete  and 
inadequate  summary. 

4.  External  medicinal  treatment. 


THERAPEUTIC  NOTES  713 

This  chapter  is  devoted  almost  exclusively  to  the  external  medi- 
cinal treatment. 

No  complete  dermatological  formulary  should  be  looked  for,  as 
I  have  on  the  contrary  endeavored  to  incorporate  in  these  notes 
only  the  customary  substances  and  prescriptions  or  those  with 
which  I  am  personally  acquainted.  It  has  long  been  may  conviction 
that  good  dermatologic  treatment  is  practicable  with  the  help  of  a 
very  limited  number  of  procedures  and  remedies.  Inexperienced 
practitioners  even  more  than  experts  in  the  field  should  refrain  from 
experimenting  with  poly-pharmacal  medication,  but  unfortunately 
the  contrary  is  often  the  case. 

The  order  followed  in  my  account  is  that  of  the  remedies  which 
correspond  to  the  clinical  indications.  Although  it  seems  to  be 
logical  and  convenient  enough,  the  fact  must  not  be  overlooked 
that  an  arrangement  on  this  basis  possesses  more  apparent  than 
real  value. 

Many  medicinal  agents,  including  some  of  the  most  valuable, 
have  an  unknown  or  hypothetical  mode  of  action;  furthermore,  the 
same  substance  may  have  multiple  effects ;  moreover,  its  action  may 
be  entirely  different,  or  even  opposite,  according  to  the  concen- 
tration in  which  it  is  employed,  according  to  the  duration  of  its 
application  and  according  to  its  pharmaceutic  form  or  its  vehicle. 

The  'pharmaceutic  form,  or  let  us  say  the  physical  state  of  an 
active  or  inert  substance  which  is  utilized  as  a  topical  agent,  has  a 
marked  influence  on  its  effects;  this  very  important  fact  has  been 
brought  out  by  the  contributions  of  Unna  and  his  school.  Some 
explanation  here  may  not  be  superfluous. 

The  skin  under  normal  conditions  is  covered  with  a  protective 
layer,  the  horny  epidermis. 

The  latter,  composed  essentially  of  keratine  and  fat,  forms  on  its 
surface  a  sort  of  supple  and  resistant  varnish,  practically  imper- 
meable to  water  and  aqueous  solutions,  but  more  or  less  permeable 
to  fatty  bodies,  volatile  substances  and  gases. 

Perhaps  the  most  important  function  of  the  horny  layer  is  to 
oppose  the  evaporation  of  water  from  the  body  tissues;  without  it, 
an  enormous  loss  of  water  would  take  place  over  a  surface  as  exten- 
sive as  that  of  the  entire  integument  and  at  the  temperature  of  the 
body.  However,  undoubtedly  due  to  the  sweat  pores  and  follicles 
with  which  it  is  riddled,  the  normal  skin  is  constantly  the  seat 
of  a  fairly  considerable  watery  evaporation  known  as  "insensible 
perspiration."  This  contributes  powerfully  to  the  regulation  of  the 
general  temperature  of  the  body  and  the  local  temperatures  of  the 
various  tegumentary  regions. 

It  is  now  necessary  to  keep  in  mind  the  modifications  which  this 


714  APPENDIX 

physiological  function  may  undergo  through  pathological  changes 
of  the  skin  on  the  one  hand  and  through  topical  applications  on  the 
other.  When  the  skin  is  congested  or  inflamed  or  when  its  horny 
covering  is  absent  or  defective,  the  evaporation  is  considerably 
increased.  Among  the  topical  agents,  those  which  tend  to  increase 
evaporation  are  necessarily  cooling  and  relieve  congestion;  whereas 
those  which  inhibit  evaporation  will  have  a  heating  and  congestive 
effect. 

The  mode  of  action  of  the  customary  agents  of  topical  treatment 
will  be  briefly  examined  in  the  following,  in  the  light  of  the  above 
data.  First,  however,  it  seems  advisable  to  point  out  a  mistake 
very  frequently  committed  in  practice,  but  which  it  is  important 
to  avoid;  it  consists  in  the  application  of  alterative  dressings, 
ointments  or  medicated  plasters  over  crusts,  scales,  or  hyperkeratotic 
layers.  Even  if  the  topical  agent  be  judiciously  selected,  it  must  be 
remembered  that  the  remedy  is  separated  from  the  surface  on  which 
it  is  to  act  by  a  stratum  or  layer  of  dead  and  isolating  substances. 
Xo  one  would  dream  of  interposing  a  sheet  of  paper  or  a  bit  of  shirt 
between  an  application  and  the  diseased  skin!  //  is  therefore  always 
necessary  at  the  start  to  cleanse,  denude  or  freshen,  every  tegumentary 
lesion  which  it  is  proposed  to  treat. 

Water  and  Watery  Solutions. — Baths,  douches,  sprays,  washes  and, 
better  still,  poultices  and  moist  occlusive  dressings  whose  action  is 
more  prolonged,  are  the  most  efficient  and  most  commonly  utilized 
cleansing  agents;  their  general  effect  is  moreover  to  relieve  conges- 
tion.   The  macerated  epidermis  becomes  more  permeable. 

Alcoholic,  Ethereal  Solutions,  etc. — Alcohol,  ether,  acetone,  chloro- 
form, benzene,  carbon  disulphide  and  carbon  tetrachloride,  all 
more  or  less  dissolve  fatty  substances,  notably  the  epidermic  fats; 
they  accordingly  have  a  cleansing  and  drying  effect.  I  habitually 
employ  a  few  drops  of  benzin  to  cleanse  the  surfaces  for  examination. 

These  bodies  likewise  dissolve  certain  medicinal  substances  insol- 
uble in  water;  by  acting  as  vehicles  they  favor  their  action,  permit- 
ting them  to  penetrate  down  to  the  vicinity  of  the  active  layers  of 
the  epidermis.  But  the  irritative  effect  of  solutions  of  this  kind 
restricts  their  application  to  a  few  special  cases. 

Powders. — By  virtue  of  their  mere  physical  properties,  powders 
increase  the  surface  of  evaporation  and  thereby  exert  a  cooling, 
drying  action  and  relieve  congestion.  These  effects  increase  with 
their  power  of  absorption. 

The  first  rank  from  this  point  of  view  belongs  to  a  f ossiferous 
earth,  known  in  France  as  "  ceyssatite;"  this  is  a  natural  product, 
an  earth  composed  of  the  silicious  shells  of  foraminifera;  a  small 
quantity  of  this  powder  suffices  to  transform  a  salve  into  a  thick 


THERAPEUTIC  NOTES  715 

paste.  The  only  objection  to  ceyssatite  is  that  it  is  not  readily 
obtainable.  [It  is  identical  with  Unna's  Kieselgur  or  Terra  silicea.] 
Other  so-called  inert  powders,  both  mineral  and  vegetable,  have  the 
same  properties,  but  to  a  lesser  degree. 

The  mineral  powders  chiefly  used  are  the  following:  talc,  zinc 
oxide,  the  carbonates  of  calcium,  magnesium  or  bismuth,  the  sub- 
nitrate  of  bismuth,  kaolin  or  bolus  alba;  vegetable  powders:  corn, 
rice  or  potato  starch,  various  flours,  lycopodium.  It  must  be  kept 
in  mind  that  starches  and  flour  have  the  disadvantage  of  swelling 
on  exposure  to  moisture  and  of  undergoing  fermentation. 

In  order  to  render  powders  more  adherent,  they  can  be  incor- 
porated in  weak  proportion  with  lotions  or  better  in  larger  propor- 
tion with  glycerinated  or  mucilaginous  fluids,  forming  watery  pastes. 
[The  popular  calamine  lotion  belongs  to  this  class  of  powders  in 
suspension  in  a  watery  fluid.  Calamine  is  (nowadays)  an  artificial 
carbonate  of  zinc  stained  a  pink  color;  a  convenient  formula  is: 
1$ — calaminse  prsep.,  3.0;  zinci  oxidi,  4.0;  glycerini,  1.0;  aq.  rosse, 
100.0  M.  Various  soluble  drugs  may  be  incorporated  in  this  mix- 
ture; e.  g.,  boric  or  salicylic  acid,  resorcinol,  etc.,  or  other  insoluble 
powders  added,  e.  g.,  sulphur  precip.] 

Glycerine. — Glycerine,  which  when  pure  is  very  hygroscopic  and 
is  miscible  with  water  in  any  proportion,  and  its  derivate,  glycerite 
of  starch,  are  less  emollient  and  less  cooling  than  watery  solutions; 
on  the  other  hand,  when  employed  in  dressings,  they  are  superior  to 
wet-dressings  in  that  they  reduce  the  risk  of  auto-inoculation  with 
pyococci.  Compared  to  fatty  bodies  they  are  less  heating,  but  lend 
less  suppleness  to  the  horny  layer. 

Glycerite  of  starch  with  an  addition  of  inert  powders  makes  a 
very  good  paste  which  can  be  mixed  with  various  active  remedies 
and  is  easily  removed  by  washing. 

Watery  Pastes. — These  are  mixtures  of  equal  parts  of  powder  and 
dilute  glycerine.  They  are  easily  prepared,  convenient  and  clean 
in  use ;  moreover,  not  expensive,  so  that  they  are  liked  by  patients 
and  deserve  their  growing  popular  favor.  They  are  applied  in  a  thin 
layer,  with  a  flat  brush,  left  to  dry  for  an  instant,  then  covered  with 
a  generous  sprinkling  of  talc;  no  dressing  is  necessary;  they  may  be 
removed  by  washing  with  water. 

The  simplest  type  of  watery  paste  is  composed  of  equal  parts  of 
zinc  oxide,  talc,  glycerine  and  water.  The  talc  may  be  replaced  by 
calcium  carbonate  or  starch.  A  number  of  liquid  or  powdery 
medicinal  agents  can  be  introduced  into  these  pastes,  such  as 
ichthyol,  coal-tar  emulsion,  lead-water,  borated  water,  lime-water, 
precipitated  sulphur,  etc.,  care  being  taken  to  observe  that  the  pro- 
portion of  glycerinated  fluid  and  powder  remains  the  same.  The 
addition  of  §  per  cent,  of  gum  Arabic  renders  these  pastes  more 


716  APPENDIX 

adherent;  the  addition  of  5  to  10  per  cent,  of  alcohol  makes  them 
more  drying. 

The  various  watery  pastes  are  especially  adapted  to  the  treat- 
ment of  the  inflammatory  and  pruritic  non-oozing  dermatitides. 

Fatty  Bodies. — The  fatty  or  oily  bodies,  which  serve  for  inunctions, 
play  an  important  part  in  dermatotherapy,  lending  themselves  well 
to  lasting  and  extensive  local  applications.  They  adhere  to  the 
epidermis  and  slightly  penetrate  it,  making  it  supple,  swelling  the 
horny  cells  and  detaching  the  scales.  But  they  prevent  the  evapor- 
ation of  the  secretions  and  the  cutaneous  perspiration  in  proportion 
to  their  impermeability  to  water,  thereby  acquiring  a  congestive 
and  heating  effect. 

In  this  respect,  enormous  differences  exist  between  the  various 
substances  designated  as  fatty  bodies  on  account  of  their  compo- 
sition. In  this  group  belong:  (1)  Fats  properly  speaking,  solid, 
pasty,  or  oily,  of  animal  or  vegetable  origin  (fresh  or  benzoinated 
lard,  beef-marrow,  whale  oil,  cacao  butter,  sweet  almond  oil,  olive 
oil,  castor  oil,  cod-liver  oil),  which  are  glycerine-ethers  or  triglycer- 
ides. Fats  admit  the  incorporation  of  only  a  very  small  proportion 
of  water;  they  are  capable  of  saponification  and  turn  rancid  in  the  air. 
(2)  Hydrocarbons,  such  as  the  vaselines,  petroleum,  paraffins,  etc.; 
these  are  not  at  all  miscible  with  water;  they  do  not  change  on 
exposure  to  the  air.  (3)  Wool  fats  (adeps  lame,  lainine,  lanoline 
[eucerine]  which  are  cholesterine  ethers;  large  amounts  of  water 
can  be  incorporated  into  them  (over  300  per  cent.),  transforming 
them  into  creams.  The  French  Codex  of  1908  designates  as  lanoline, 
wool-fat  mixed  with  water  to  a  proportion  of  25  per  100. 

The  consistence  of  the  fatty  bodies  may  be  arbitrarily  varied  by 
combining  those  which  are  liquid,  such  as  the  oils,  or  of  slightly  fluid 
consistence,  such  as  lard  and  vaseline,  with  more  viscid  fats,  like  the 
wool-fats,  or  solid  fats,  like  beef-marrow,  spermaceti,  cacao  butter, 
or  even  with  wax  or  paraffin.  The  resulting  mixture  retains  the 
general  properties  of  its  constituents. 

There  are  other  additions,  notably  those  of  powders  or  water  in 
considerably  proportion,  which  modify  not  only  the  consistence,  but 
also  very  notably  the  immediate  effects  of  the  fatty  bodies. 

Salves. — Salves  are  natural  or  combined  fatty  bodies  into  which 
one  or  several  medicinal  substances  has  been  incorporated.  As 
these  salves  are  always  more  or  less  impermeable  to  the  cutaneous 
perspiration,  they  have  a  heating,  congestive  effect,  as  mentioned 
above;  but  at  the  same  time  they  favor  the  real  and  deep  action  of 
the  active  substances  contained  in  them. 

Salve  Sticks. — Mixed  with  wax,  paraffin,  etc.,  salves  may  be 
moulded  into  sticks,  which  are  easy  to  manipulate  and  very  con- 
venient. 


THERAPEUTIC  NOTES  717 

Pastes. — By  mixing  the  fatty  bodies  with  a  considerable  quantity 
of  powders  (on  the  average,  equal  parts  of  fats  and  powders),  fatty 
pastes  are  obtained.  These  soften  and  protect  the  skin  surface  on 
which  they  are  applied;  they  moreover  possess  the  essential  property 
of  being  porous,  permeable  to  perspiration,  consequently  relieving 
congestion.  Medicinal  substances  incorporated  into  a  paste  have  a 
moderate  action,  intermediate  between  that  of  salves  on  the  one 
hand  and  of  creams  and  watery  pastes  on  the  other. 

Creams. — Creams  are  formed  by  an  intimate  admixture  of  fatty 
bodies  with  a  large  proportion  of  water  or  of  watery  solutions. 

The  relative  quantity  of  water  contained  in  the  different  creams 
is  very  variable;  17  per  cent,  in  cold  cream;  33  per  cent,  in  "Galien 
cerate;"  43  per  cent,  in  "cucumber  cream;"  50  per  cent  in  oil-  and 
lime-water  liniment.  Mixtures  of  wool-fats  and  vaseline  are  best 
adapted  to  the  manufacture  of  creams  very  rich  in  water  (up  to 
1000  to  100)  and  do  not  turn  rancid. 

Creams  cannot  serve  for  active  treatment,  but  are  cooling  and 
softening. 

Milks,  several  varieties  of  which  are  offered  in  trade  (notably  the 
milk  of  Sapolan,  the  collosols,  etc.),  are  emulsions  of  hydrocarbons, 
lanoline,  etc.,  and  possess  analogous  although  mild  properties. 

Soapy  salves  are  useful  as  cleansing  agents. 

Occlusive  Dressings. — Zinc  gelatine  is  permeable  to  perspiration 
and  has  a  protective  action,  relieving  congestion  and  itching. 

Plasters,  sparadraps  or  epithems,  are  formed  by  some  tissue  or 
fabric  covered  with  a  layer  of  a  plastic  substance  of  such  consistence 
as  to  adhere  firmly  to  the  skin.  The  older  plasters,  consisting  of 
litharge,  lard  and  various  resins,  which  are  apt  to  crack  and  fre- 
quently have  an  irritating  effect,  are  now  advantageously  replaced 
by  plasters  prepared  with  a  base  of  lanolin  or  vaseline,  caoutchouc 
and  a  little  wax.  Practically  all  external  dermato-therapeutic  agents 
may  be  incorporated  into  these  plasters,  in  variable  proportions.  It 
must  be  kept  in  mind  that  all  plasters,  being  impermeable,  prevent 
evaporation  and  cutaneous  perspiration,  so  that  they  have  a  heating 
and  congesting  effect. 

Varnishes  soluble  in  water  (caseine  ointment,  gelanthum  and 
analogous  preparations)  have  not  been  adopted  in  current  derma- 
tological  practice.  [A  varnish  of  ichthyol  and  water,  equal  parts, 
is  valuable  in  many  acute  erythematous  conditions,  e.  g.,  acute 
dermatitides,  erysipelas,  etc.] 

Ether  varnishes  (collodion),  acetone  (filmogen)  ["new-skin"]  and 
chloroform  varnishes  (traumaticine)  are  employed  only  in  certain 
special  conditions. 


718  APPENDIX 

After  this  brief  review  of  the  pharmaceutic  forms  under  which 
the  medicinal  agents  used  in  dermato-therapy  are  employed,  these 
agents  will  now  be  considered  as  such,  arranged  by  their  therapeutic 
indications.  1  repeat  the  reservations  previously  stated  concerning 
the  value  of  this  classification. 

Where  a  series  of  simple  or  compound  substances  appear  in  the 
same  paragraph,  they  may  be  regarded  as  analogous;  but  they 
differ  necessarily  among  themselves  by  shades  which  I  have  not 
always  found  it  possible  to  indicate. 

The  somewhat  complex  combinations  have  been  presented  in  the 
form  of  prescriptions,  sometimes  signed  with  the  name  of  their  best 
known  author.  It  should  be  clearly  understood,  however,  that  there 
is  nothing  binding  about  these  prescriptions;  the  excipients  have 
been  purposely  varied,  to  serve  as  examples,  so  that  a  given  excipient 
may  always  be  replaced  by  some  other  of  analogous  consistence  and 
the  same  physical  properties. 

The  majority  of  the  prescriptions  are  given  on  a  basis  of  about  100 
parts,  as  an  aid  to  memory;  it  is  left  to  the  physician  to  estimate  the 
quantity  of  remedy  required  in  a  given  case. 

[It  may  be  useful  to  remember  that  25  grams  of  a  soft  ointment, 
of  the  consistence  of  vaseline,  is  ample  for  a  single  inunction  over 
the  entire  cutaneous  surface  of  an  adult;  twice  that  amount  is 
hardly  enough  to  cover  the  surface  with  a  firm  paste  like  Lassar's.] 

1.  ANTIPHLOGISTICS. 

Antiphlogistic,  sedative,  cooling  and  emollient  treatment  is  em- 
ployed in  the  acute  dermaiitides  in  general,  in  the  active  erythemas, 
eczema,  etc.  Cases  in  which  it  is  indicated  are  therefore  extremely 
common.  It  comprises  several  procedures  between  which  a  selection 
must  first  be  made  according  to  circumstances,  but  which  are  often 
employed  in  combination  or  successively. 

These  procedures  consist  of  the  use,  under  different  forms,  of 
water  and  watery  solutions,  especially  to  be  recommended  when 
crusted  surfaces  have  to  be  cleaned  at  the  same  time;  of  powders 
and  watery  pastes;  of  creams,  milks,  or  glycerites  and  more  rarely, 
of  fatty  pastes  or  salves. 

Lotions  {washes). — Preferable  to  simple  boiled  water  is  an  infusion 
of  camomile  flowers,  lime-  or  elderblossoms,  or  a  decoction  of  ele- 
campane roots,  marshmallow,  etc.,  or  some  isotonic  solution  may 
be  used,  such  as  physiological  salt  solution,  or  better  the  cytoplastic 
solution  of  Professor  Delbet  (magnesium  chloride,  dry,  12.10,  or 
crystallized  magnesium  chloride  25.85,  to  one  liter  of  water)  with 
which  I  have  been  especially  well  pleased  of  recent  years.    Weak 


ANTIPHLOGISTICS  719 

antiseptic  and  astringent  solutions  may  also  be  employed   (§2). 
Lotions  should  usually  be  applied  hot  and  several  times  daily. 

Sprays. — The  above-mentioned  solutions  may  be  employed  as 
sprays,  by  means  of  a  Richardson  apparatus  or  vapor  spray,  repeated 
several  times  daily. 

Moist  Occlusive  Dressings. — These  are  used  every  day  in  derma- 
tology even  more  than  in  surgery. 

Moist  dressings  consist  of  compresses  of  sterilized  gauze,  soaked 
in  one  of  the  above-mentioned  infusions,  decoctions  or  solutions, 
well  squeezed  out  so  as  to  be  merely  damp,  then  applied  so  as  to 
cover  widely  the  affected  region;  they  are  covered  with  an  imper- 
meable layer  of  rubberized  cloth,  oil-silk,  or  gutta-percha,  with  a 
margin  to  spare  on  all  sides;  next,  with  a  layer  of  cotton;  the  whole 
is  held  in  place  by  a  bandage.  These  dressings  should  generally  be 
applied  cold;  they  must  be  really  occlusive  and  be  renewed  once  or 
twice  in  the  twenty-four  hours.  [The  Liq.  aluminii  acetatis  diluted 
with  10  to  15  parts  of  water  is  especially  valuable  for  its  astringent 
and  mildly  antiseptic  properties.] 

Poultices. — On  account  of  their  mucilaginous  consistence,  these 
are  often  better  tolerated  than  moist  dressings.  They  are  prepared 
as  follows:  Mix  with  two  spoonfuls  of  cold  water,  a  spoonful  of 
mashed  potato  or  starch;  slowly  pour  this  dilution  into  a  sauce- 
pan containing  eight  spoonfuls  of  boiling  water  for  the  mashed 
potato,  not  more  than  six  spoonfuls  for  the  starch,  stirring  to  a 
jelly;  then  spread  on  muslin,  folding  the  borders  over  the  mixture. 
Linseed  meal,  the  oil  of  which  turns  rapidly  rancid,  is  not  to  be 
recommended.  Ready-made  starch  and  other  poultices  are  on  the 
market  which  only  need  to  be  softened  in  a  little  luke-warm  water. 

Poultices  are  applied  cold  or  barely  luke-warm  and  renewed  two 
or  three  times  daily;  it  is  not  usually  necessary  to  cover  them  with 
an  impermeable  material.  [Salicylic  acid,  one  per  cent.,  or  boric 
acid,  5  per  cent.,  may  advantageously  be  dissolved  in  boiling  water 
in  preparing  these  poultices.] 

Baths. — Aside  from  local  warm  baths,  which  are  indicated  for 
example  in  lymphangitis,  general  baths  of  pure  water,  baths  of  starch 
water,  lime  blossom  decoctions,  gelatins,  etc.,  are  oftener  harmful 
than  useful  in  erythemas,  urticarias,  acute  eczemas  and  especially  in 
the  presence  of  a  complicating  pyodermatitis. 

Alcohol  Dressings. — This  therapeutic  procedure,  inherited  from 
Ambroise  Pare,  is  not  sufficiently  appreciated.    It  is  highly  useful 


720  APPENDIX 

and  may  serve  at  the  onset  to  abort  furuncles  and  carbuncles, 
lymphangitic  abscesses,  bvbos,  etc.  The  compresses  should  be  soaked 
in  9o°  or  90°  alcohol,  no  weaker;  covered  with  impermeable  material 
and  renewed  every  twelve  or  twenty-four  hours,  according  as  the 
occlusion  has  been  more  or  less  perfect. 

Powders. — It  has  been  previously  stated  that  absorbent  or  inert 
powders  are  far  from  being  useless;  they  have  on  the  contrary  a 
cooling,  drying  action  and  [by  increasing  the  surface  for  evaporation] 
evidently  relieve  congestion. 

Various  powders  are  often  combined  and  coloring  substances  may 
be  added  to  the  mixture  if  desired  by  the  patient,  or  they  may  be 
rendered  slightly  antiseptic  or  antipruritic. 

Two  examples  follow,  meeting  each  of  these  two  indications: 

PULVIS   CUTICOLOR    (UNNA). 

Rice  starch 40.0  gr. 

Zinc  oxide 25.0 

Magnesium  carbonate 20.0 

Bolus  alba 12.5 

Bolus  armenian 2.5 

COMPOUND    POWDER. 

Talc,  venet 40.0  gr. 

Calcii  carbonat. 
Magnesii  carbonat. 

Zinci  oxidi aa     20.0 

Ichthyol  or  gomenol 1  to  2 . 0 

Ointments. — The  only  ones  usually  to  be  recommended  in  cases 
of  acute  dermatitis  are  watery  pastes,  creams,  and  sometimes 
glycerites,  etc. 

Watery  pastes  may  be  simple  or  compound: 

SIMPLE   WATERY   PASTES. 

Zinc  oxide,  talc,  glycerin,  water equal  parts 

or 

Zinc  oxide,  calcium  carbonate,  glycerin,  lime-water     .      .     equal  parts 

COMPOUND   WATERY  PASTES. 
Zinc  oxide, 

Starch aa,     25.0  gr. 

Glycerin, 

Water aa     20.0 

Ichthyol 10.0 

Gum  Arabic,  powd 0.5 

These  pastes  are  applied  with  a  flat  brush,  left  to  dry  for  half  a 
minute,  then  covered  freely  with  talc. 

Among  the  creams,  namely  mixtures  of  fatty  bodies  and  a  large 


ANTIPHLOGISTICS  721 

proportion  of  water,  may  be  quoted:  cold  cream,  Galien  cerate, 
cucumber  cream,  lime-  and  oil-liniment  (almond  oil  and  lime-water 
in  equal  parts).  I  prefer  the  following  creams,  because  they  do  not 
turn  rancid: 

VASO-LANOLINE. 

Petrolati 10.0  gr. 

Lanolini  anhydr 5 . 0  gr. 

Aq.  rosae, 

Aq.  lauro-cerasi, 

Aq.  aurant.  flor aa       5.0 

Triturate  well,  adding  the  waters  drop  by  drop.  If  lime-water  be  substituted  for 
oneof  the'scented  waters  the  emulsion  is  facilitated  and  keeps  better. 

CREAM  OF  STEARATE  OF  SODA. 

Liq.  sodse 5.0 

Ac.  stearic 25.0 

Glycerin 75.0 

Aq.  rosffi 120.0 

Heat  and  mix ;  solidify  by  cooling,  then  heat  again,  stirring  vigorously. 

QUININE  VASOLANOLINE  (PREVENTIVE  OF  SOLAR  ERYTHEMA). 

Petrolati 10.0 

Lanolin  anhydr 5.0 

Aqueous  solution  of  neutral  bromhydrate  of  quinine  1  to  15  .  15.0 
Apply  before  exposure  to  the  sunlight  and  powder  with 

Talcum 15.0 

Basic  quinin  sulphate 1.0 

Certain  oils  (pyroleol  of  Edet,  phlyctol  of  Robert  and  Carriere, 
which  are  compound  purified  and  sterilized  oils  of  melilotus),  applied 
in  dressings,  have  a  soothing  and  truly  analgesic  action,  valuable 
in  burns,  phagedena  and  gangrenous  ulcers. 

Starch  glycerite,  Sapolan  cream,  soapy  salves  and  "diadermine" 
which  is  a  glycerite  of  stearates,  can  sometimes  substitute  the 
creams. 

Milks,  Sapolan  or  others,  which  are  emulsions  of  lanoline  and 
hydrocarbons,  are  cooling  and  much  liked  by  patients. 

In  the  acute  dermatitides,  pastes  and  especially  salves  should  be 
avoided;  they  are  often  very  badly  tolerated;  fresh  lard,  however, 
is  frequently  very  soothing. 

When  the  inflammation  is  plainly  subacute,  simple  pastes  or 
pastes  with  a  slight  admixture  of  ichthyol  may  prove  serviceable. 

LASSAR'S   PASTE. 
Zinc  oxid, 
Starch, 
Vaselin, 
Lanolin aa     equal  parts 

SOFT    PASTE   OF   UNNA. 
Zinc  oxide, 
Prepared  chalk, 
Linseed  oil, 

Lime-water aa    equal  parts 

46 


APPENDIX 


GLYCEROL   ICHTHYOL    PASTE. 

Neutral  glycerite  of  starch 70.0 

Kaolin, 

Magnesium  carbonate aa     15.0 

Ichthyol 3  to  5 . 0 

ZINC,   OIL   AND   ICHTHYOL. 

Olive  oil  washed  with  alcohol 40.0 

Zinc  oxide 60.0 

Ichthyol 1  to  3 .  0 


2.  WEAK  ANTISEPTICS  AND  ASTRINGENTS. 

It  has  come  to  be  understood,  especially  of  recent  years,  that 
antiseptics  applied  for  the  purpose  of  killing  the  microbes  or  inhibit- 
ing their  growth,  are  at  the  same  time  injurious  to  the  tissues,  the 
more  so  in  proportion  to  their  activity.  It  is  therefore  not  practi- 
cable to  disinfect  a  wound  or  an  infected  cutaneous  surface  all  at 
once  by  means  of  a  strong  antiseptic.  In  order  to  attain  this  end, 
or  at  least  to  favor  the  organism  in  its  fight  against  the  infecting 
agents  and  thereby  to  assist  the  cure,  only  so-called  cytophylactic 
substances  should  be  employed,  namely  substances  which  spare  the 
cells;  or  mild  antiseptics  as  slightly  injurious  to  the  body  tissues 
as  possible. 

Lotions  and  Sprays. — In  the  majority  of  the  cases,  it  is  advisable 
in  my  opinion  not  to  make  an  excessive  use  of  lotions.  When  there 
is  reason,  however,  for  cleansing  a  wound,  an  ulcer,  or  an  infected 
dermatosis,  one  of  the  following  watery  solutions  may  be  employed: 
the  classical  borated  water  (boric  acid  4  :  100),  boricine,  or  biborate 
of  soda  obtained  by  the  action  of  boric  acid  on  borax,  in  equal  parts 
and  hot  (4  to  10  :  100),  dilute  peroxide  water,  weak  carbolized  water 
(phenol  1  :  100),  resorcinated  water  (resorcinol  1  :200),  phenosalyl 
or  a  solution  of  phenol  salicylate  (1  :  200),  decoctions  of  cinchona, 
oak  bark  or  other  astringent,  tannic  acid  decoctions,  and  finally  a 
solution  of  lead  subacetate  [Liq.  plumbi  subacetat.  dil.]. 

Matchless,  in  my  opinion,  is  Alibour  water  [copper  and  zinc 
sulphate  in  camphorated  water]  which  renders  me  every  day  the 
most  valuable  service  and  Labarraque's  fluid,  or  the  officinal 
solution  of  soda  hypochlorite,  which  should  be  diluted  with  water  to 
4  to  10  times  its  volume;  or  better  still,  Dakin's  solution.  Burrow's 
solution  [Liq.  alumin.  acetat.]  is  extensively  used  abroad. 

ALIBOUR   WATER    (PYODERMATITIDES). 

( lupric  sulphate 2.0 

Zinc  sulphate 7.0 

Camphor  water  saturated 300.0 

Filter;  for  use  dilute  a  tablespoonful  or  two  to  a  glass  of  water. 


WEAK  ANTISEPTICS  AND  ASTRINGENTS  723 

burrow's  solution  (oozing  dermatitides)  . 

Alum     .      .      . 1.0 

Plumbic  acetate 5.0 

Water 100.0 

Not  to  be  filtered;  shake  before  use  and  dilute  with  5  to  20  volumes  of  water. 

[Burrow's  solution  is  best  prescribed  as  liq.  alumini  acetatis;  diluted  before  use 
with  10  to  20  volumes  of  water.] 

Moist  Antiseptic  Dressings. — All  the  above  enumerated  solutions 
may  be  employed  for  moist  occlusive  dressings,  of  course  in  their 
weakest  solutions.  The  only  exception  is  Alibour  water,  which  is 
inefficient  in  dressings,  in  my  experience.  The  question  of  the 
aseptic,  antiseptic  and  other  dressings  will  be  taken  up  later  on. 

Baths. — Local  baths,  with  mild  antiseptics,  may  be  useful  in  the 
acute  dermatitides  and  lymphangitides  of  the  limbs  and  of  the  penis. 
For  general  baths,  I  make  use  only  of  zinc  sulphate  (20  to  40  grams 
for  a  full  bath)  in  the  generalized  pyodermatitides. 

Solutions  for  Painting,  Touching,  etc. — Although  they  must  not  be 
abused,  it  may  be  useful  to  know  the  preparations  which  may  be 
employed  in  ulcers,  atonic  wounds,  folliculitis,  herpes,  etc.  Tincture 
of  iodine  is  really  used  to  excess  at  the  present  time,  but  is  never- 
theless valuable  for  painting,  as  well  as  iodo-acetone  (2  to  5  :  20) 
or  iodo-chloroform  (1  to  15),  for  aborting  boils  and  in  the  epidermo- 
mycoses.  The  Lugol-Gram  solution  (iodine,  1  gr.  KI,  2  gr.,  water 
300  gr.)  serves  for  tuberculous  or  mycotic  ulcers;  iodoform  ether 
(1  :  20),  guaiiacol  oil  (equal  parts),  gomenol  oil  (5  to  20  :  100),  in 
tubercidous  or  sluggish  idcers;  camphorated  iodoform  oil  (3  :  10  :  100) 
makes  a  good  dressing  for  soft  chancres  and  bubos  (Dinet).  Cam- 
phorated alcohol  (1  :  100),  borated  alcohol  (1  :  16),  alcohol  with 
resorcin  (1  :  50)  or  alcohol  with  thymol  (1  :  100)  and  borated  glycer- 
ine (1  :  100)  or  carbolized  glycerine  (1  :  50)  are  useful  for  touching 
or  brief  application  during  a  few  minutes  in  herpes  and  folliculitides 
such  as  furuncles  of  the  auditory  meatus,  etc. 

Gargles  {stomatitis  and  buccal  ulcerations). — Dilute  Labarraque's 
solution  (50  :  1000),  hydrogen  peroxide  water,  "Neol"  (1  :  10),  a 
few  drops  of  tincture  of  ratanhia  or  myrrh  in  a  glass  of  water; 
decoction  of  snake-weed  (bistorta)  (20  :  1000);  astringent  gargles 
with  alum,  sodium  borate,  potassium  chlorate;  chloral  hydrate 
(1  to  1.50  :  100),  etc.,  with  glycerine  or  honey. 

A  soapy  tooth-paste  should  also  be  recommended,  containing 
sodium  borate  or  extract  of  ratanhia,  etc. 

GARGLE. 
Sodium  chlorate, 
Sodium  salicylate, 

Sodium  bicarbonate aa       2.0 

Honey 75.0 

Water 225.0 


724  APPENDIX 


TOOTH-PASTE. 

Soap 10.0 

Carbonate  of  lime, 

Tricalcic  phosphate aa  20. 0 

Carmin 0.1 

Oil  of  peppermint 3.0 

Collutories. — Iodized  glycerine  (iodine  and  carbolic  acid  aa  0.25, 
KI,  1.0;  glycerine  50)  in  buccal  ulcerations;  borated  glycerine 
(4  :30);  or  borated  honey  (5  :  20),  For  thrush;  honey  with  alum 
(5  :30). 

Powders. — Iodoform,  pure  or  camphorated  (5  :  100)  and  its  sub- 
stitutes: iodol  (iodopyrol),  diiodoform  (C2I4),  aristol  (diiodothymol 
or  ihyrrvoliodide  of  Poulenc;  europhen  (butocresiol) ,  airol  (oxyiodo- 
gallate  of  bismuth  or  alphaform);  dermatol  or  officinal  bismuth 
subgallate;  xeroform  (tribromophenate  of  bismuth  or  sigmaform); 
chemically  pure  methylene  blue;  tannoform  (formotan);  subearbon- 
ate  of  iron;  cinchona,  etc. 

To  these  more  or  less  antiseptic  powders  which  can  be  prepared 
in  mixtures,  as  will  be  shown  by  an  example,  Vincent's  powder  has 
been  added  since  1017,  which  is  very  efficient  through  the  nascent 
chlorine  given  off  from  it  and  but  slightly  irritant;  it  acts  as  a 
powerful  preventive  of  infection  on  recent  jagged  wounds;  more- 
over it  yields  good  results  in  infected  wounds  and  ulcers  of  variable 
character  and  even,  in  my  experience,  in  soft  chancre  and  chancroidal 
bubo. 

COMPOUND   POWDER  OF  J.  LUCAS  CHAMPIONNIERE. 

Iodoform, 
Benzoin  powder, 

Cinchona  powder aa,  100.0 

Magnesium  carbonate, 

01.  eucalyptus 12.5 

Vincent's  powder. 

Hypochlorite  of  lime 10.0 

Boric  acid,  dry 90.0 

Powder  separately,  mix  well  and  preserve  in  a  dry  dark-glass  bottle. 

Ointments. — Creams,  glycerites,  pastes  or  salves  may  be  employed, 
in  different  cases,  salves  being  the  most  active;  one  or  several  of 
the  following  remedies  are  incorporated:  Yellow  oxide  of  Hg.  (5  to 
10  :  100);  white  precipitate  (1  to  10  :  100);  camphor  (1  :  100); 
boric  acid  (5  to  10  :  100);  salicylic  a?id  (1  to  2  :  100);  resorcinol 
(1  to  2  :  100);  naphthol  (0.5  to  1  :  100);  or  various  essential  oils: 
gomenoloil  (5  to  50  :  100). 

YELLOW  SALVE  (PYODERMATITIDES) . 
Yellow  oxide  of  mercury, 

Oxide  of  zinc aa,     10.0 

Resorcinol, 

Salicylic  acid aa,       1.0 

Vaselin 78.0 


WEAK  ANTISEPTICS  AND  ASTRINGENTS  725 

ICHTHYOLATED   YELLOW   PASTE    (iMPETIGENIZED   ECZEMA). 

Ichthyol, 

Yellow  oxide  of  mercury aa       5.0 

Resorcinol, 

Salicylic  acid aa       1.0 

Oxide  of  zinc, 

Talcum aa     20.0 

Vaselin 48.0 

Ichthyolated  Lassar's  paste  (5  per  cent.)  with  an  addition  of 
resorcinol  (1  :  100)  or  salicylic  acid  (1  :  100)  is  extremely  useful 
and  in  daily  use;  the  nature  of  the  fats  or  powders  which  enter 
into  the  composition  of  the  excipient  may  be  arbitrarily  changed, 
incorporating  at  will  reducing  agents,  keratoplastic  or  antipruritic 
agents,  etc. 

Starch  glycerite  with  boric  acid  (100  :  10)  is  the  topical  applica- 
tion of  choice  in  the  treatment  of  boils,  carbuncles  and  the  pyoder- 
matitides  in  general  (Gallois). 

Cold  cream  is  a  favorite  vehicle  for  white  precipitate  (1  to  10: 100). 
with  or  without  addition  of  tannin  (1  to  5  :  100). 

Borated  vaseline  is  in  common  use  as  a  weak  antiseptic  salve. 
It  is  also  employed  for  the  nasal  fossa?. 

gomenol-resorcinol  salve  (rhinitis,  folliculitis  of  the 

nostrils)  . 

Boric  acid 10.0 

Resorcinol 2.0 

Gomenol 1.0 

Vaselin 50.0 

YELLOW  EYE-SALVE  (BLEPHARITIS,    IMPETIGINOUS   CONJUNCTIVITIS). 

Yellow  oxide  of  mercury 0.15 

Guaiacol 0.05 

Lanolin 6.0 

Vaselin  oil 10.0 


Varnishes. — Antiseptic  varnishes  find  their  indications  in  certain 
dermatitides  with  an  intact  epidermis  (lymjihangitis,  erysipelas); 
in  these  cases,  thigenol,  pure  ichthyol  or  glycerinated  liquid  thiol 
(fluid  thiol,  85;  glycerine,  15)  are  serviceable;  on  the  other  hand 
as  occlusives  (fissures,  rhagades,  ulcerations  of  mucous  membranes), 
use  can  be  made  of  complex  varnishes  composed  of  various 
resins  and  balsams  dissolved  in  alcohol  or  ether,  which  are  generally 
found  ready-made  in  the  drug  stores;  such  as  Baume  de  Com- 
mandeur  (Codex);  steresol  (Berlioz,  Grenoble);  adhesol  (Leclerc). 
Varnishes  having  an  aseptic  action  through  their  physical  properties 
will  be  discussed  later  on. 


726  API'EXDIX 


■  I.  STRONG  ANTISEPTICS. 

The  statements  made  at  the  beginning  of  the  preceding  paragraph 
suggest  that  the  indications  for  strong  antiseptic  agents  are  rare 
and  limited. 

The  solutions  and  mixtures  to  be  indicated  in  the  following  must 
under  no  circumstances  be  employed  for  dressings,  as  they  would  be 
too  irritating  and  even  caustic.  They  have  to  be  reserved  for  washes, 
touching  or  painting. 

Watery  Solutions. — Bichloride  of  mercury  or  corrosive  sublimate 
(1  to  2  :  1000);  biniodide  of  mercury  (1  :  1000);  cyanide  of  mercury 
2  to  5  :  1000;  oxy cyanide  of  mercury  (5  :  1000);  strong  carbolized 
water  (phenol  5  :  1000);  "microcidine"  or  naphtholate  of  sodium 
(3  to  5  :  1000);  strong  hydrogen  peroxide  water  (12  to  20  volumes) 
"  lusoform,"  "aniodol,"  or  watery,  alcoholic  or  glycerinated  solu- 
tions of  formol   (0.25  to  1  :  1000)'. 

Various  Solutions. — Tincture  of  iodine;  iodized  acetone  (1  to  3  :  10 
camphorated  naphthol  (2  :  1);  camphorated  phenol  (equal  parts); 
camphorated  salol  (3:2). 

menctere's  fluid  (lacerated  wounds,  ulcers,  etc.). 

Iodoform, 
Guaiacol, 

Eucalyptol, 

Bals.  Peruv aa       1.0 

Alcohol 10.0 

Ether 100.0 

To  be  used  as  a  spray  or  for  painting. 

CALOT'S  COMPOUND  SOLUTION   (TUBERCULOUS  ULCERATIONS  AND 
COLD  ABSCESSES). 

Guaiacol 1-0 

Creosote 2.0 

Iodoform 9.0 

Camphorated  naphthol 20.0 

Ether, 

Olive  oil  (sterilized) aa  34.0 

Ointments. — The  following  two  salves  enjoy  a  certain  popularity: 

RECLUS'  SALVE  (SLUGGISH  ULCERS)  MODIFIED  BY  BROCQ  AND  II.  PIED. 

Phenol  crystal, 

Salicylic  acid aa  1.0 

Resoreinol 2.0 

Camphor, 

Antipyrin iia  5.0 

Bals.  Peruv 6.0 

Vaselin 80.0 

Dissolve  the  first  four  substances  in  a  little  alcohol  and  glycerin;  dissolve  the 
antipyrin  in  its  own  weight  of  water;  then  triturate  the  whole  in  a  mortar. 


Antipruritic  Agents  And  local  Anesthetics    727 

OINTMENT  OF  LUCAS-CHAMPIONNIERE    (BURNS). 

/3-Naphtholate  of  soda 0.3 

Oil  of  thyme, 

"     geranium, 

"     verbena, 

"     origanum aa     gtt.  xv 

Vaselin 100.0 

4.  ANTIPRURITIC  AGENTS  AND  LOCAL  ANESTHETICS. 

For  the  local  treatment  of  pruritus,  a  series  of  procedures  and 
remedies  may  be  utilized. 

Watery  Solutions. — These  are  usually  more  efficient  when  hot, 
although  sometimes  they  act  better  luke-warm  or  cold.  Decoction 
of  elecampane  root  (20  :  1000);  bran  water;  infusion  of  chamomile 
blossoms  (20  :  1000)  or  lime-tree  flowers  (10  to  15  :  1000);  an 
infusion  of  coca  leaves  (10  to  20  :  1000);  lime-water;  cherry-laurel 
water;  chloral  hydrate  (2  to  4  :  100);  Labarraque's  solution  (20 
to  50  :  100);  phenol  (1  to  5  :  100);  saponin  coal-tar  (10  to  30  :100); 
sapolan  milk,  collosol  with  oil  of  cade  or  cod-liver  oil,  etc.  [Liq.  picis 
alk.  or  Liq.  carbonis  deterg.  10  :  100.] 

Baths. — These  are  often  badly  tolerated.  Starch  or  bran  baths 
are  sometimes  prescribed,  with  an  addition  of  vinegar  (1  liter) ;  or 
baths  of  lime-tree  flowers  (1  kilo);  finally,  gelatine  baths  (250  to 
500  gr.  of  gelatine,  soften  in  cold  water,  dissolve  while  heating  and 
pour  into  bath). 

Various  Solutions. — For  painting  or  touching,  the  following  are 
employed:  Camphorated  alcohol  (1  :  10),  or  camphorated  brandy 
(1  :  40),  or  camphorated  chamomile  oil  (1  :10);  resorcin  alcohol 
(2  to  5  :  100);  menthol  alcohol  (1  to  2  :  100);  or  mentholated  oil  of 
vaseline  (1  to  2  :  100);  carbolized  glycerine  (phenol  5,  water  and 
glycerine,  aa  50);  alcoholic  solutions  of  silver  nitrate  (3  to  10  :  100); 
lemon  juice. 

Especially  advantageous  are  the  alcoholic  solutions  of  thymol 
(1 :  200),  of  carbolic  acid  (1 :  100),  of  coal-tar  emulsion  (5  to  10: 1000), 
to  which  castor  oil  or  glycerine  (5  to  10  :  100)  are  added  to  prevent 
their  too  rapid  drying;  cover  with  powder  or  a  watery  paste. 

ANTIPRURITIC   SOLUTIONS. 
Vinegar, 
Camphorated  alcohol, 

Aq.  lauro-cerasi ■ aa  100.0 

Glycerin 50.0 

Dilute  with  4  to  10  parts  of  water. 

Cocain  muriate, 
Chloral  hydrate, 

Resorcinol aa  1.0 

Glycerin 3.0 

Alcohol 20.0 

Aq.  lauro-cerasi 30.0 

Water 44.0 


728  APPENDIX 

Ointments. — The  application  of  a  fatty  substance  on  a  pruritic 
region  sometimes  suffices  to  bring  considerable  relief  to  the  patient; 
fresh  lard,  cerate  or  pure  vaseline  may  serve  for  this  purpose;  the 
preference  is  often  accorded  to  sapolan,  naphtalan,  pure  cod-liver 
oil,  in  compound  salves,  or  better  in  the  form  of  collosol. 

Needless  to  say,  it  is  often  very  advantageous  to  incorporate  one 
or  several  of  the  antipruritic  substances  with  the  salves  or  pastes. 
Tse  is  frequently  made  of  starch  glycerite  with  tartaric  acid  (5: 100), 
or  a  mentholated  oil  with  chloroform  (camphorated  oil  of  chamomile, 
100,  chloroform  2  to  5,  menthol  1.) 

Ethyl  para-amido-benzoate  (anesthesine  or  benzocaine  of  Poulenc) 
is  employed  (10  to  30  :  100)  in  a  lanolin  cream  mixed  with  alcohol  or 
olive  oil  (10  to  30  :  100) ;  or  also  in  a  mucilage  of  gum  Arabic.  Ortho- 
form  (orihocaine)  should  be  rejected  on  account  of  the  severe  erup- 
tions and  intoxications  which  it  may  cause. 


SALVE. 

Menthol 1.0 

Chloral  hydrate, 

Camphor aa  5.0 

Lanolin 35.0 

Vaselin 50.0 

PASTE. 

Menthol 0.5 

Phenol 1.0 

Salicylic  acid 2.0 

Tumenol 5.0 

Lassar's  paste 90.0 

COD-LIVER  OIL  SALVE. 

Cod-liver  oil 5.0  to  30.0 

Olive  oil 5.0  to  25.0 

White  wax 5.0 

Paraffin 8.0 

Aq.  rosae, 

Aq.  lauro-cerasi      .  aa     10.0 

Occlusive  Dressings. — Undoubtedly  the  mere  fact  of  protecting 
the  diseased  surfaces  from  the  air  represents  a  valuable  measure  for 
the  control  of  pruritus.  Salves  and  pastes  evidently  owe  to  this  a 
considerable  share  of  their  efficiency.  Poultices  with  starch,  moist 
dressings  and  properly  applied  cotton  wraps  likewise  secure  good 
occlusion,  provided  the  affected  surfaces  are  not  too  extensive. 
"Zinc  gelatin,"  which  is  applicable  to  large  surfaces,  if  desired,  is 
still  more  practical;  here  follows  the  fundamental  formula  and  a 
modified  formula  so  as  to  render  the  gelatin  harder  in  the  warm 
season  of  the  year: 

Gelatin 15  or  30  gr. 

Zinc  oxide 15  or  10  gr. 

Glycerin 25  or  30  gr. 

Water 45  or  30  gr. 


ANTIPRURITIC  AGENTS  AND  LOCAL  ANESTHETICS    729 

The  mass  is  liquefied  in  the  water-bath,  applied  with  a  flat  brush, 
then  while  the  coating  is  still  viscid,  the  surface  is  dusted  with  ab- 
sorbent cotton  which  adheres  to  it  and  gives  it  the  appearance  of 
swan-skin.  A  zinc-gelatin  covering  may  be  left  in  place  for  several 
days;  it  is  removed  by  stripping  or  by  means  of  warm  water. 

With  this  zinc-gelatin,  ichthyol  or  other  active  substances  may  be 
incorporated;  it  is  preferable  to  apply  these  substances  by  painting 
them  on  first,  after  which  the  surface  is  covered  with  the  gelatin. 

Varnishes  and  Plasters. — The  entire  series  of  tars  and  analogous 
substances  may  serve  as  a  siccative  coating,  either  in  the  natural 
state  (coal-tar,  vegetable-tar,  ichthyol,  thiol,  tumenol,  thigenol,  etc.), 
or  in  the  form  of  extracts,  or  ether  and  alcoholic  or  various  other 
solutions. 

The  ordinary  plasters  can  nearly  all  be  utilized  for  the  treatment 
of  localized  pruritus.  For  this  purpose,  use  is  made  especially  of 
zinc  oxide  plaster,  resorcinol  or  phenol  plaster,  red  oxide,  or  cod- 
liver-oil  plaster,  etc. 

When  treating  pruritus  and  prurigo  by  topical  medication,  one 
must  never  omit  adding  advice  concerning  hygiene,  hydrotherapy, 
the  employment  of  electricity  under  various  forms,  hot  air,  hyper- 
tonic sera,  etc. 

Local  Anesthesia. 

This  is  very  exceptionally  indicated  in  the  cutaneous  neuralgias 
or  dermatalgias  (zona,  herpes,  etc.);  in  such  cases,  hot  poultices, 
or  ichthyol,  guaiacol,  carbolized  and  other  solutions  indicated  above 
and  painted  on,  are  usually  sufficient. 

To  spare  the  patient  the  pain  of  certain  small  operations  such 
as  scrapings,  scarifications,  rather  extensive  biopsies  (tuberculosis 
verrucosa,  lupus,  proliferations,  tumors),  there  are  several  methods. 
The  quickest  is  freezing  with  a  jet  of  ethyl  chloride,  which  has 
replaced  the  bag  of  salted  ice,  stypage  with  methyl  chloride,  etc. 
Much  more  complete  and  durable  is  anesthesia  by  injection  of  a 
solution  of  cocaine  chlorhydrate  (|  to  2  :  100)  locally  or  along  the 
course  of  the  regional  nerves  (fingers,  penis,  etc.),  the  patient  must 
have  eaten  and  be  in  the  recumbent  position;  it  is  advisable  not  to 
exceed  the  dose  of  0.02  at  the  head,  0.05  elsewhere.  The  addi- 
tion of  a  few  drops  of  adrenalin  or  of  carbolic  acid  (chlorhydrate 
of  cocaine  2,  phenol  cryst.  0.50  to  1.0,  water  100)  favors  anesthesia; 
Schleich  in  his  infiltration  method  showed  that  very  weak  concen- 
trations are  sufficient  (chlorhydrate  of  cocaine,  0.10  to  0.20,  sodium 
chloride  0.20,  water  100).  Less  toxic  than  cocaine  are  allocaine, 
stovaine,  etc.;  I  usually  employ  a  solution  of  novocaine  to  which 
adrenalin  is  added  just  before  use  (novocaine  0.50  or  1.0,  water 


7: 10  APPENDIX 

100,  adrenalin  „'„,],  10.0  to  25.0).  It  is  essential  after  injecting 
analgesic  agents  to  wait  at  least  fifteen  or  twenty  minutes  before 
operating. 

Bonin's  mixture  (chlorhydrate  of  cocaine,  menthol,  carbolic  acid, 
aa  equal  parts)  is  very  efficient  when  painted  over  mucous  mem- 
branes, ulcers  and  excoriated  surfaces. 

5.  CLEANSING  AND  KERATOLYTIC  AGENTS. 

This  group  of  therapeutic  agents  is  applicable  to  the  scaly  or 
crusted  dermatoses  and  to  the  keratoses. 

Baths. — To  cleanse  large  surfaces,  soapy  baths  may  be  utilized 
or  alkaline  baths  (sodium  carbonate  60  to  250  gr.)  or  sulphurous 
baths  (hepar  sulphuris  60  to  100  gr.).  Vapor  baths  and  dry  air  baths, 
at  70°  or  80°  (160°-175°  F.)  or  over,  act  also  through  the  sweating 
produced  by  them. 

Lotions. — Any  soap  with  a  soda  base  may  be  used  for  soapy  washes. 
In  city  practice,  patients  prefer  a  prescription  of  some  medicated 
soap;  ichthyol,  lanolin,  salicylic  acid,  tar,  sulphur,  naphthol  soaps, 
etc.,  are  the  most  commonly  used. 

Potash  soaps,  which  are  soft,  are  more  keratolytic  than  soda 
soaps.  Black  soft  soap  is  uninviting;  but  a  white  odorless  potash 
soap  can  be  made. 

The  alkalimetric  titration  of  the  commercial  soaps  varies  in  con- 
siderable proportions.  It  may  prove  advantageous  to  render  them 
less  irritating  by  transforming  them  into  super-fatted  soaps. 

WHITE  POTASH  SOAP  (VICARK)). 

Cocoanut  oil 200 . 0 

Caustic  potash,  c.p 70.0 

Water 600.0 

Saponify  hot  and  boil  down  to  500.  To  make  this  soap  super-fatted,  add  stearin 
and  water,  aa  20,  to  each  100. 

LIQUID  SUPERFATTED  SOAP  (FOR  SURGICAL  USE). 

Green  soap, 

Castile  soap aa     20 . 0 

Olive  oil 17.0 

Oil  of  geranium  or  lemon q.  s. 

Water 1000.0 

Filter. 

A  decoction  of  quillaya  (50  :  1000),  quillaya  extract  and  saponine 
are  preferable  to  soaps  for  the  cleansing  of  the  scalp. 

Gentle  rubbing  with  a  wad  of  absorbent  cotton  moistened  with 
alcohol,  ether,  or  better  with  benzine,  very  efficiently  cleanses  the 
skin. 


CLEANSING  AND  KERATOLYTIC  AGENTS  73 1 

An  excellent  measure  for  cleansing  a  cutaneous  surface  covered 
with  crusts  and  scales  consists  in  applying  moist  dressings  or  a 
poultice  during  several  hours. 

Ointments. — A  simple  application  of  vaseline,  almond  oil,  lard, 
starch  glycerite,  a  stearate  such  as  diadermine,  etc.,  often  suffices 
for  the  softening  and  detachment  of  the  scales.  For  the  scalp,  beef 
marrow  or  mixtures  of  fats  are  in  favor,  such  as: 

Cocoa  butyr 30 

Almond  oil 70 

01.  rosse gtt.  i 

It  is  sometimes  advantageous  to  make  inunctions  with  a  soapy 
foam  which  is  allowed  to  dry  upon  the  skin  (kerosis,  acne).  Soapy 
ointments  are  very  practical  and  can  be  employed  on  the  scalp,  on 
account  of  the  facility  of  cleansing  with  a  wad  of  cotton  moistened  in 
water. 

SOAPY  SALVE. 
Powd.  soap, 

Lard aa     40.0 

Almond  oil 20.0 

01.  geranii gtt.  iv 

Heat  the  fats  to  150°  C.  (302°  F.)  before  introducing  the  soap  powder. 

SOAP  SALVE  (CARLE  AND  BOTTLED). 

Lard 50.0 

Potash 17.5 

Water 300.0 

Alcohol 10.0 

Lanolin 20.0 

Boil  down  to  120. 

With  these  salves  may  be  incorporated  a  large  number  of  the 
usual  medicinal  substances,  notably  sulphur,  but  not  bodies  which 
are  incompatible  with  alkalis,  such  as  pyrogallol,  chrysarobin,  acids 
in  general,  mercurial  salts,  etc. 

Soft  soap  in  inunctions  has  a  very  powerful  cleansing  action  (lupus 
erythematodes ,  pityriasis  versicolor) ;  but  it  is  very  irritating  and  its 
effects  must  be  watched. 

Salicylic  acid  is  the  keratolytic  agent  par  excellence.  In  weak 
dosage  (1  :  100),  it  figures  in  many  pastes  or  salves  as  a  mordant 
and  antipruritic  agent;  in  stronger  dosage  (5  :  100)  in  vaseline,  it 
constitutes  the  most  habitually  used  detersive  agent  (psoriasis, 
ichthyosis,  keratosis  pilaris);  in  benzoinated  lard  and  castor  oil 
(5  :  200),  especially  when  immediately  covered  with  an  imper- 
meable tissue,  or  in  the  form  of  an  ointment  or  varnish,  it  displays 
its  maximum  activity  (keratoderma,  circumscribed  hyperkeratoses). 

Acetic  acid  and  lactic  acid  also  have  a  keratolytic  action. 


732  APPENDIX 

Resorcinol,  which  in  weak  doses  acts  as  a  keratoplasty  agent,  is  on 
the  contrary  in  strong  doses  (5  to  50  :  100)  an  excellent  detersive 
and  even  exfoliating  agent.  The  last  named  property  is  utilized 
in  the  following  preparations  which  are  destined  to  serve  for  exfoli- 
ation cures  {acne,  kerosis,  flat  warts,  pigmentations).  Resorcine  may 
be  combined  with  soft  soap. 

MIXTURE  FOR  FLAT  WARTS. 
Arctic  acid  (glacial), 

Lactic  acid aa     10.0 

Precipitated  sulphur 20.0 

Glycerin 40.0 

Apply  cautiously;  an  analogous  mixture  may  he  made  with  ac.  salicyl.  or  with 
phenol. 

KERATOLYTIC  SALVE  FOR  SEVERE  ACNE  OF  TRUNK  (BROCQ). 

Resorcinol, 

Camphor aa  10.0 

Potash  soap 15.0 

Precipitated  sulphur 30.0 

Creta  prep 5.0 

Vaselin 30.0 

Apply  for  five,  then  ten,  then  fifteen  minutes  before  a  hath. 

EXFOLIATING  PASTE. 

Resorcinol 40.0 

Zinc  oxide 10.0 

Kaolin 5.0 

Benzoated  lard 25.0 

Unna  [modified]. 

EXFOLIATING  MIXTURE. 

Resorcinol 20.0  to  30.0 

Potash  soap, 

Sulphur aa     20.0 

Spts.  lavandulse 30.0  to  40.0 

Plasters  and  Varnishes. — In  the  case  of  circumscribed  keratoses  and 
verrucosities,  potash  soap  plasters,  and  especially  salicylated  plasters, 
render  excellent  service.    Collodium  is  also  frequently  employed. 

COLLODIUM  FOR  CORNS. 

Collodii  flex 10.0 

Absolute  alcohol 6.0 

Ether,  sulph 4.0 

Salicyl.  acid 2.0 

Ext.  canabis  Indica 1.0 

COLLODION  FOR  PAPILLARY  WARTS. 

Collodii  flex 10.0 

Absolute  alcohol 6.0 

Ether  sulph 4.0 

Ac.  salicyl 2.0 

A(".  lactic ,      .  1.0 


BLEACHING  AGENTS  733 


6.  BLEACHING  AGENTS. 

Bleaching  agents  are  employed  in  the  treatment  of  hyperchromias, 
ephelides,  chloasma,  etc.,  and  of  hypertrichosis  of  the  face  in  women. 

Lotions  (washes). — Vinegar  may  be  utilized,  or  weak  solutions  of 
hydrochloric  acid  (1  to  2  :  500),  lemon  juice,  also  watery  or  alcoholic 
watery  solutions  of  sublimate  (1  to  2  :  500),  etc. 

For  hairs  of  the  face,  reliance  can  be  placed  only  on  applications 
of  peroxide  water  repeated  several  times  daily,  or  on  the  peroxide 
cream  a  prescription  for  which  follows: 

LOTIONS    FOR   CHLOASMA. 

Hydrarg.  bichlorid 1.0 

Alcohol q.  s. 

Plumbi  acetat., 

Zinci  sulphat aa       2.0 

Aq.  distillata 250.0 

(Hardy.) 
Hydrarg.  bichlorid., 

Ammonii  chlorid aa       0.1 

Emulsion  of  almonds 100.0 

(Brocq.) 
In  this  formula,  tinct.  benzoin  5.0  may  be  substituted  for  the  ammon.  chlorid. 

The  applications  must  be  made  in  the  morning  and  again  in  the 
evening;  during  the  night,  salves  or  ointments  are  applied. 

Ointments. — Creams,  pastes  and  salves  which  contain  sufficiently 
strong  proportions  of  hydrogen  peroxide,  acetic  acid,  mercurial  salts, 
or  sulphur  and  naphthol,  possess  a  more  or  less  strong  bleaching 
action. 

PEROXIDE  CREAM 

Hydrogen  peroxide  water ,      .      .      .      .  15.0 

Vaselin 10.0 

Lanolin 5.0 

Oxide  of  zinc 1.0 

Bichloride  of  mercury       .., 0.5 

F.  hebra's  SALVE. 
Calomel, 

Bismuth  subnitr aa       6.0 

Lard  or  vaselin 90.0 

The  most  energetic  treatment  of  pigmentations  consists  in  the 
employment  of  exfoliation  by  means  of  strong  resorcin  pastes  or 
mixtures  [but  they  have  only  a  temporary  effect]. 

Plasters. — Mercurial,  carbojized  mercurial  and  red  plaster  are 
useful. 


734  APPENDIX 

Whatever  remedy  has  been  employed,  the  treatment  must  be 
interrupted  for  a  few  days  as  soon  as  the  skin  becomes  reddened  and 
inflamed;  the  irritation  should  be  soothed  by  means  of  a  cream,  or 
a  starch  glycerite  with  an  addition  of  bismuth  carbonate  and  kaolin 
(aa20  :  100). 

7.  REDUCING  AGENTS. 

Under  this  name  we  include  a  series  of  extremely  valuable  derma- 
tological  remedies  which  have  the  common  feature  of  being  more  or 
less  avid  of  oxygen.  This  property,  according  to  Unna,  accounts  for 
their  biological  action. 

Weak  reducing  agents,  or  even  strong  reducing  agents  employed 
in  weak  dosage  or  for  a  short  time,  are  keratoplastic,  antiseptic, 
relieve  congestion  and  itching.  Strong  reducing  agents  are  exfoli- 
ating, highly  irritative  and  give  rise  to  severe  epidermo-dermatitis. 

Judging  from  my  experience,  in  conformity  with  that  of  Jadassohn, 
the  progressive  order  of  activity  of  the  usual  reducing  agents  is 
apparently  as  follows:  mercurial  salts,  resorcinol,  sulphur  and  sul- 
phur-containing remedies,  tars  (ichthyol,  thiol,  tumenol,  coal-tar, 
wood-tar,  oil  of  birch,  oil  of  cade);  the  most  energetic  are  undoubt- 
edly pyrogallol  and  chrysarobin. 

The  therapeutic  investigation  of  a  large  series  of  derivates  of 
these  substances,  which  have  been  extolled  as  less  toxic  and  less 
irritative,  has  been  carried  out  only  outside  of  France  and  not 
always  with  the  necessary  thoroughness  and  disinterestedness.  It 
is  useful  to  know  the  names  of  some  of  these:  lenigallol  or  tripyrate 
(tri-acetate  of  pyrogallol),  eugallol  or  mono-pyrate  (mono-acetate), 
saligallol  (disalicylate) ;  gallanol,  eurobine  or  trichrysate  (triacetate 
of  chrysarobine),  etc. 

Reducing  agents  are  employed  under  the  most  varied  forms  in 
kerosis  and  its  complications,  in  the  dry  psoriatiform  and  lichenoid 
eczemas,  in  2)soriasis,  in  the  parakeratoses  in  general,  in  the  lichens, 
etc. 

In  the  choice  of  excipients  and  combinations,  the  fact  must  be  kept 
in  mind  that  the  wood-tars  (of  pine,  juniper;  or  cade  oil,  etc.),  have 
an  acid  reaction,  whereas  mineral  or  coal-tar  is  alkaline. 

Watery  Lotions. — Ichthyol  (sulpho-ichthyolate  of  ammonium)  and 
thigenol  are  the  only  tars  soluble  in  water.  In  order  to  render  the 
other  tars  miscible  with  water,  they  must  be  emulsified  with  the 
assistance  of  saponine  (saponined  coal-tar)  or  in  certain  excipients 
such  as  retinol  (a  product  of  dry  distillation  of  colophane);  the 
opalol  of  Caillat  and  the  collosol  of  Pepin  are  neutral  soaps  in  which 
various  tars  can  be  emulsified;  their  use  is  clean  and  very  con- 
venient. The  tars  are  also  incorporated  into  solid  soaps  (ichthyol 
soap,  tar  soap,  cade  oil  soap,  etc.). 


REDUCING  AGENTS  735 

Sulphur  is  rarely  employed  dissolved;  in  carbon  bisulphide,  etc., 
it  is  dangerous;  a  very  active  commercial  solution  comes  in  cedar  oil, 
known  as  denisol  (7  per  cent,  of  sulphur).  The  general  preference 
is  to  employ  sulphur  either  in  suspension  or  in  the  colloidal  state 
(denisoline),  in  lotions,  either  in  the  state  of  sulphides,  or  in  soaps 
(sulphur  soaps,  sulphur-naphthol  soaps). 

The  following  two  prescriptions  are  of  every-day  use: 

CAMPHORATED  SULPHUR  LOTION    (KEROSIS,  ACNE,  ROSACEA, 
ECZEMATIDES) . 

Precipitated  sulphur 10.0 

Spts.  of  camphor 20.0 

Glycerin 5.0 

Rose  water, 

Water aa  q.  s.  ad  100.0 

SULPHUR  LOTION  (PITYRIASIS  CAPITIS,  SEBORRHEA) . 

Potassium  sulphuret 2 . 0  to  4 . 0 

Water 100.0 

Or  preferably: 

Potass,  sulphuret.  liquid,  30  to  100  drops  to  a  i  glass  of  hot  water. 

[The  following  is  a  useful  modification  of  the  well-known 

LOTIO  ALBA   (ACNE,  KEROSIS,  ETC.). 

Solution  sat.  zinci  sulphatis, 

Solution  sat.  potassii  sulphuretti aa     50 . 0 

Spts.  odorati    , 10.0 

To  this  mixture,  beta  naphthol  0.5,  or  resorcinol  2.0,  or  some- 
times glycerin  10.0,  may  be  added.] 

Soluble  mercurial  salts  may  also  serve  in  lotions: 

ACID  MERCURIAL  LOTION  (ACNE) . 

Hydrarg.  bichlorid 0.2 

Ac.  acetic 1.0 

Tct.  benzoin 5.0 

Kaolin 5.0 

Alcohol 20.0 

Aquai 70.0 

MERCURIAL  LOTION  FOR  THE  SCALP. 

Hydrarg.  bichlorid 0.2 

Ammonii  chlorid  (or  resorcinol  or  chloral  hydrate)      .      .      .      .  1.0 

Aq.  lauro-cerasi            ■. 10.0 

Water • 90.0 

Moist  Dressings. — Under  this  form  I  have  employed  only  resorcinol 
(0.25  to  1  :  100)  and  especially  ichthyol  (2  to  10  :  100),  with  favor- 
able results. 


736  APPENDIX 

Baths. — There  is  no  advantage  in  the  employment  of  reducing 
agents  in  the  form  of  baths.  However,  sulphur  baths  (hepar 
sulphuris  50.0  to  100.0)  and  the  so-called  Bareges  baths  enjoy  a 
classical  reputation. 

bareges'  bath. 

Sodium  monosulphide 60.0 

Sodium  chloride  (dry) 60.0 

Sodium  carbonate 30.0 

For  one  bath. 

TAR  BATH  (BALZER). 

Oil  of  cade 50  to  100.0 

Fl.  extr.  quillaya 10.0 

Yolk  of  one  egg, 

Water 250.0 

For  one  bath. 


Alcoholic  and  Ethereal  Lotions. — Washes  of  this  kind  are  applicable 
in  the  treatment  of  kerotic  affections  of  the  hairless  skin  (seborrhea, 
acne)  or  more  especially  of  analogous  affections  of  the  hairy  scalp. 
When  the  scalp  is  very  dry,  castor  oil  (1  to  5  :  100)  may  be  added  to 
the  alcoholic  lotions.  The  prescriptions  here  given  as  examples 
may  be  combined  in  a  variety  of  ways  with  stimulating  mixtures. 

LOTIONS  FOR  THE  SCALP  (PITYRIASIS,  KEROTIC  ALOPECIA). 

1.  Beta-naphthol 0.10 

Hydrarg.  bichlorid 0 .  20 

Resorcinol, 

Amnion,  chloride, 

( 'liloral  hydrat aa       0.5 

Spts.  lavandulse 100.0 

2.  Hydrarg.  bichlor 0.10 

Ac.  salicyl 0.20 

Liq.  carbonis  deterg. 

Spts.  sether., 

Spts.  rosmarini aa,     15.0 

Spts.  vini 55.0 

3.  01.  Rusci, 

01.  cadini aa       1.0 

Tct.  quillaya: 20.0 

Alcohol  (60  per  cent.) 80.0 

Ointments. — According  to  the  degree  and  depth  of  action  which  it 
is  desired  to  obtain,  use  is  made  of  creams,  pastes  or  salves. 

The  creams  are  prepared  with  cold  cream,  cerate,  vasolanoline, 
or  starch  glycerite,  incorporating  calomel  (2  to  10  :  100),  turpeth 
mineral,  yellow  oxide  of  jncrcury  (2  to  5  :  100)  or  precipitated 
sulphur  (2  to  30  :  100). 


REDUCING  AGENTS  737 

In  France,  oil  of  cade  is  traditionally  used  in  psoriasis  in  the  form 
of  glycerite: 

CADE  OIL  GLYCERITE.  Mild.  strong. 

01.  cadini 15.0  50.0 

Saponis  viridis  or  extr.  quillaya  (to  emulsify)   .      .  q.  s.  5.0 

Glycerite  of  starch  neutral 85.0  45.0 

01.  caryophyl q.  s.  q.  s. 

A  glycerite  can  be  transformed  into  a  paste  by  adding  to  it  kaolin 
and  magnesium  carbonate  (aa  10  to  15  :  100) ;  the  glycerites  have 
the  advantage  of  permitting  easy  cleansing  of  the  skin. 

Pastes  are  more  active  and  more  convenient  to  use;  their  con- 
stituents may  vary  practically  indefinitely.  The  following  pre- 
scriptions are  commonly  employed  by  me  (figured  or  psoriasiform 
eczematides,  lichenoid  eczemas,  etc.) : 

ICHTHYOL  SULPHUR  PASTE. 

Sulphur  precip 3.0 

Ichthyol 5.0 

Resorcinol 1.0 

Zinci  ox., 

Starch aa       8.0 

Petrolati, 

Lanolin aa      10.0 

TAR  SULPHUR  PASTE.  eak.  strong. 

Sulphur,  precip 3.0  5.0 

01.  cadini 5.0  10.0 

Ac.  salicyl 1.0  1.0 

Resorcinol -. 1.0  1.0 

Zinci  ox., 

Talci aa  20.0  18.0 

Petrolati 50.0  47.0 

The  formulas  of  these  pastes  can  be  well-nigh  indefinitely  modified 
by  changing  the  nature  of  the  powders  or  the  fats;  by  replacing  the 
ichthyol  and  cade  oil  with  birch  oil  or  other  tars,  or  with  extracts 
several  satisfactory  types  of  which  are  on  the  market  (oleocade, 
oxycade);  by  employing  other  forms  of  sulphur,  or  by  introducing 
mercurial  salts.  It  should  be  remembered  that  except  in  the  case 
of  cinnabar  (red  mercuric  sulphide),  the  association  of  sulphur  and 
mercurials  produces  a  black  sulphide. 

Salves  are  more  particularly  adapted  to  obstinate  cases  and  to 
the  treatment  of  certain  regions. 

The  reducing  agent  is  customarily  introduced  in  a  dose  of  5  :  100 
and  the  mordant  (salicylic  acid,  resorcinol)  in  a  dose  of  1  :  100,  but 
there  are  numerous  exceptions. 

For  the  scalp  (kerosis,  pityriasis,  seborrhea,  psoriasis),  Sabouraud 
considers  sulphur  and  sulphur  derivatives  as  especially  adapted  to 
the  oily  forms  and  cade  oil  or  its  substitutes  to  the  scaly  condi- 
47 


7:  is  APPENDIX 

tions.  \  irginia  cellar  oil  lias  been  shown  by  him  to  be  capable  of 
assisting  or  replacing  cade  oil,  which  bas  a  very  unpleasant  odor, 
in  lotions  or  ointments. 


SALVES  FOR  THE  SCALP  AND  BEARD. 

1.  Sulphur  precip., 

01.  rusci aa       5.0 

Resorcinol 1.0 

Ongt.  Sapon.  (Section  5) 90.0 

2.  01.  cedri 

01.  cadini  deodorisati aa        5.0 

Hydrarg.  ox.  flav. 

Resorcinol aa        1.0 

Petrolati, 

Lanolin aa      10.0 

(Sabouraud.) 

FOR  THE  FACE  (PITYRIASIS,  ECZEMATIDES) . 

1.  Calomel,  vap.  parat., 

Tannin,  alcoh.  parat aa       3.0 

Vaselin 100.0 

2.  Sulphur  precipi, 
Cinnabar, 

Bals.  Peruv aa       3.0 

Vaselin 100.0 

FOR  THE  BODY.      COMPOUND  SALVE  (PSORIAM-    . 
Pyrogallol, 
Ac.  salicylic, 

Resorcinol aa       1.0 

Sulphur  precip., 
01.  rusci, 

Ol.  cadini aa       2.0 

Vaselin, 
Lanolin, 
Adipis aa     20  to  2.5.0 

STRONG  PYROGALLIC  SALVE   (OBSTINATE  LICHENOID  ECZEMA, 
PSORIATIFORM  ECZEMATIDEs) . 

Pyrogalloli 6.0 

Ac.  salicyl 3.0 

Picis  liq., 

Ichthyol aa  20.0 

Cerati 50.0 

The  employment  of  pyrogallol  salves  must  be  very  closely  watched 
on  account  of  the  poisoning  threatened  by  this  agent.  I  have  found 
that  ehrysarobin  salves  of  very  weak  concentration  il  :  4(10  to 
1  :  300  in  lard),  which  have  been  recommended  on  various  sides 
(Jadassohn,  Sabouraud)  are  practicable  when  properly  prepared 
and  cautiously  employed  in  progressive  doses  (pityriasis  rosea, 
eczematides). 


REDUCING  AGENTS  739 

[dreuw's  ointment  (psoriasis,  lichen  simplex  chronicus, 
keratoid  eczemas,  etc.). 

Ac.  salicylic 10.0 

01.  rusci, 

Chrysarobini aa  20.0 

fPetrolati 20.0 

■j 01.  theobromat .  5.0 

[Saponis  viridis 25.0 

(Modified.)  An  unscientific  but  powerful  and  effective  reducing  agent.  To  be 
used  in  courses  of  five  days  followed  by  a  three-  to  five-day  course  of  Lassar's  paste.] 

Certain  mixtures,  although  containing  active  substances  in  fairly 
strong  dosage,  are  often  admirably  tolerated,  even  in  acute  attacks 
of  eczema.  Caution  in  their  use  is  nevertheless  indicated;  after 
the  cutaneous  susceptibility  of  the  patient  has  been  tested  by  appli- 
cations of  brief  duration,  they  may  be  employed  in  permanent 
inunctions. 

COMPOUND  BALSAM  (MODIFIED  DTJRET'S  BALSAM). 

Resorcinol 2.0 

Menthol, 

Guaiacol • aa       5.0 

01.  cadini, 

Sulphur  ppti aa     15.0 

Picisliq 18.0 

Sodii  boratis .      .36.0 

Camphor, 

01.  ricini aa     40 .  0 

Glycerini .      .      .54.0 

Aceton 80.0 

Lanolin 100.0 

laillier's  salve  (keratodermas). 

Sulphur  ppti., 

01.  cadini, 

Picis  liquid, 

Saponis  viridis        .      .      .      . aa     25 . 0 

CHAULMOOGRA   SALVE    (PRURIGO) . 

Chaulmoogra  oil 5.0 

Sulphur 8.0 

Camphor 12.0 

Tar 15.0 

Vaselin 62 . 0 

Modified  Baissade  balsam. 

Paints  and  Varnishes. — It  is  sometimes  advantageous  to  employ 
reducing  agents  by  applying  them  with  a  brush  and  covering  with  a 
powder,  a  zinc  paste  or  a  varnish.  This  is  a  practical  method  of 
employing  chrysarobin;  the  latter  is  also  very  conveniently  used 
in  the  form  of  pomatum-  or  salve-sticks. 


740  APPENDIX 

Pyrogallol 5  to  10.0 

Ether  sulph., 

Spts.  vini  rect aa     45.0 

Cover  with  a  layer  of  zinc-paste. 

Chrysarobin 10.0 

Chloroform 90.0 

( 'over  with  traumaticin  : 

Gutta-percha 10.0 

Chloroform 90.0 

CHRYSAROBIN  SALVE-STICKS. 

Chrysarobin 10.0 

Petrolati 30.0 

Cerae 30.0 

Butyr.  cacao 20.0 

Paraffini  duri 10.0 

Incorporate  the  chrysarobin  with  the  vaselin,  melt  the  other  ingredients  and  mix. 
Cool  in  cylindrical  molds. 

Solutions  of  various  tars,  coal-tar  as  well  as  vegetable  tars,  may 
be  prepared  in  alcohol-ether,  or  in  benzol  and  acetone,  applied  with  a 
brush  and  covered  with  a  zinc  paste.  They  are  sometimes  incor- 
porated with  collodion. 

TINCTURE  OF  TAR  (SACK). 

Coal  tar 10.0 

Benzol 20.0 

Acetone 70.0 

Use  unfiltered. 

OIL  OF  CADE  COLLODION  (LICHEN  PLANUS). 

Collodii  flex 15.0 

Alcohol  absolut., 

Ether aa  4.0 

01.  cadini 5.0 

Ol.  rusci 1.0 

Dind  (Lausanne)  and  Brocq  have  brought  into  vogue  applica- 
tions of  crude  coal-tar  previously  washed  to  free  it  from  the  excess 
of  alkali. 

The  coal-tar  is  spread  over  the  skin  by  means  of  a  brush,  allowed 
to  dry,  then  dusted  with  talc  powder;  the  application  is  touched  up 
every  day  or  every  other  day  and  the  coating  is  allowed  to  act  during 
four  to  eight  days.  Far  from  being  as  irritative  as  one  might  believe, 
coal-tar  is  as  a  ride  readily  tolerated  under  this  form,  even  in  cases 
of  oozing  eczema;  in  hospital  practice,  it  advantageously  replaces 
the  compound  balsams  which  are  far  more  expensive.  Unfortu- 
nately, coal-tar  is  not  a  definite  product  and  its  composition  varies 
enormously,  according  to  its  source. 


CICATRIZING  AND  KERATO PLASTIC  AGENTS  741 

Plasters. — In  the  form  of  plasters  the  reducing  agents  exert  an 
energetic  action.  The  most  common  are  mercurial,  resorcinol,  oil 
of  cade  and  tar  plasters;  it  is  noteworthy  that  pyrogallol  and 
chrysarobin  plasters  are  not  well  tolerated. 

8.  CICATRIZING  AND  KERATOPLASTY  AGENTS. 

A  medicinal  agent  produces  neither  cicatrization  nor  epidermisa- 
tion;  these  are  curative  effects  on  the  part  of  the  organism. 

The  physician's  part  is  limited  to:  (1)  protecting  the  cutaneous 
lesions  against  external  irritants  and  against  secondary  infections; 
(2)  putting  them  in  the  best  possible  condition  for  the  fight  against 
the  microbes  and  for  a  proper  repair;  (3)  accessorily,  stimulating  a 
sluggish  repair-process. 

In  this  respect  it  is  greatly  to  the  interest  of  the  dermatologist  to 
take  into  consideration  the  experience  of  operating  surgeons  and 
proceed  in  conformity  therewith.  For  a  number  of  years  there  was 
a  tendency  to  replace  antiseptic  methods  by  the  aseptic  treatment 
of  simple  wounds.  In  the  course  of  the  great  war,  it  was  soon  recog- 
nized in  case  of  primarily  or  secondarily  infected  wounds  that  the 
at  first  very  popular  painting  with  iodine  as  well  as  applications  of 
peroxide  water,  ether,  permanganate,  etc.,  were  inadequate  and  even 
injurious. 

Surgical  "toilet",  as  timely  and  complete  as  possible,  followed 
by  progressive  antisepsis,  are  favored  at  the  present  day. 

In  cutaneous  pathology,  conditions  are  different  from  those 
obtaining  in  surgery.  I  shall  endeavor  to  arrange  the  problems  which 
arise  under  a  small  number  of  headings. 

Aseptic  or  Slightly  Infected  Lesions. — For  admittedly  clean  surgical 
wounds,  aseptic  dressings  are  sufficient.  Traumatic  wounds,  which 
are  always  infected  or  promptly  liable  to  infection,  burns,  chemical 
dermatitis,  etc.,  should  be  treated  by  one  of  the  following  measures: 

Moist  dressings  with  weak  antiseptic  solutions,  selecting  the  least 
irritating;  the  so-called  cytophylactic  solutions  (§1)  are  especially  to 
be  recommended,  such  as  that  of  Prof.  Delbet  (Acad,  des  Sciences 
and  Acad,  de  Med.,  Sept.,  1915). 

Very  interesting  in  its  principle,  convenient  and  economical,  is 
the  mechanically  antiseptic  fixogen  dressing,  devised  by  Mouchet 
and  Loudenot  (Archiv.  de  Med  et  de  Pharm.  milit.,  Jan.,  1917,  p. 
97).  It  consists  of  a  varnish,  at  first  known  as  fixol,  analogous  but 
preferable  to  the  various  mastisols,  aseptofix,  etc.;  it  is  employed  by 
painting  it  on  the  wound  or  the  lesion  and  its  surroundings,  without 
preliminary  disinfection;  it  is  not  irritative,  agglutinates  microbes, 
opposes  their  entrance  and  firmly  fixes  the  layers  of  aseptic  gauze 
with  which  it  is  covered  after  a  minute's  drying. 


742  APPENDIX 

The  paraffinizaticm  of  wounds  and  burns  by  fusible  mixtures 
(ambrine)  accomplishes  a  non-adherent  isolation,  which  has  the 
fault,  however,  of  being  impermeable  to  secretions.  I  have  previ- 
ously stated  that  the  dressing  of  burns  and  painful  dermatitides 
with  fixed  oils  to  which  essential  oils  have  been  added  (gomenol  oil, 
for  example)  or  with  compound  oils  known  as  pyroleol  or  phlyctol 
which  are  analgesic  and  aseptic,  is  preferable  in  my  opinion. 

Infected  Wounds  and  Ulcerations. — Progressive  moist  antiseptic 
dressings,  the  borated  sodium  hypochlorite  solution  of  Carrel- 
Dakin  (calcium  chloride  200,  sodium  carbonate  100,  sodium  bicar- 
bonate 50,  boric  acid  for  neutralizing;  the  solution  to  be  prepared 
extemporaneously)  employed  as  a  continuous  local  bath,  has  proved 
to  be  extremely  valuable  for  the  sterilization  of  war-wounds  and  is 
worthy  of  being  likewise  applied  to  the  treatment  of  certain  ulcers. 

Dressings  with  the  polyvalent  serum  of  Leclainche  and  Vallee 
(serum  of  horses  which  have  been  immunized  against  the  germs  of 
the  various  suppurations),  by  favoring  phagocytosis  and  regener- 
ation of  the  anatomical  constituents,  accomplish  both  physiological 
antisepsis  and  cytophylaxis  (Presse  Medicale,  April  2,  1917,  p.  187). 

Progressive  chemical  disinfection  can  also  be  aimed  at  by  the 
employment  of  various  powders.  Vincent's  powder  (§2)  seems  to  me 
superior  to  iodoform  and  its  analogues,  to  ectogen,  etc.  Calcium 
chloride  in  the  natural  state,  arsenobenzol  as  a  powder,  etc.,  are 
customarily  employed  on  ulcerations  of  mucous  membranes; 
methylene-blue  still  has  its  adherents. 

Various  antiseptic  salves,  the  ingredients  of  which  have  been 
given  above  (see  Sections  2  and  3),  notably  Reclus'  salve,  are  also 
considered  as  assisting  cicatrization.  Colloid  silver  salve  (10  :  100) 
is  entitled  to  special  mention. 

Rhagades  chaps,  cracks. — These  are  treated  either  by  mild  cauteri- 
zations, or  by  painting  them  with  steresol,  adhesol,  Commandeur's 
balsam,  or  balsam  of  Peru. 

Sluggish  Cicatrizations. — Cauterizations  with  silver  nitrate, 
chromic  acid,  etc.,  will  check  exuberant  granulations.  Grafts  are 
indicated  on  extensive  granulating  surfaces  and  promise  a  more 
flexible  and  less  contracting  cicatrix. 

In  case  of  sluggish  ulcers,  recourse  may  be  had  either  to  strong- 
antiseptics,  stimulants  and  mild  caustics,  or  to  styrax  ointment 
and  its  analogues,  as  well  as  balsam  of  Peru.  Occlusion  by  diachy- 
lon or  medicated  plasters,  or  by  zinc-gelatin,  is  sometimes  sufficient. 
Heliotherapy,  light-baths,  hot-air  douches,  high  frequency  currents, 
are  sometimes  of  the  greatest  value. 


STIMULANTS  AND  RUBEFACIENTS  743 

It  must  not  be  neglected  to  place  the  affected  limb  in  a  suitable 
position  and  to  order,  according  to  the  cases,  either  immobilization 
or  on  the  other  hand,  systematic  gymnastic  exercises. 

9.  STIMULANTS  AND  RUBEFACIENTS. 

These  are  employed  in  the  passive  erythemas,  in  hyperidrosis  of  the 
feet,  in  the  alopecias,  in  lupus  erythemafodes,  etc. 

They  are  represented  by  alcohol,  alcoholic  preparations  and 
tinctures,  ether,  chloroform,  the  volatile  oils,  camphor,  mustard, 
iodine  and  the  acids,  which  supply  the  basis  of  the  majority  of 
stimulating  topical  agents;  the  latter  are  almost  invariably  used 
in  the  form  of  liniments: 

Liniments. — for  frost-bite,  hyperidrosis,  etc.: 

1 .  Tinct.  iodin  (or  tannin) 1  to  5 .  0 

Spts.  camphor 100.0 

2.  Spts.'terebenth. 3.0 

Spts.  camphor 47.0 

Spts.  saponat 50.0 

3.  Aq.  ammonia?  fort 5.0 

Spts.  camphor 15.0 

01.  amygdal.  dulc 80 .  0 

4.  Ac.  tannici, 
Resorcinol, 

Ichthyol aa       2.0 

Glycerini 10.0 

FOR  STATIONARY  LUPUS  ERYTHEMATODES  AND  ALOPECIA. 

Phenolis, 

Tinct.  iodi, 

Chloral  hydrat aa       5.0 

Paint  on  the  surface. 

FOR  ALOPECIA  AREATA . 

Ac.  acetic  glacial 1-0 

Chloral,  hydrat 4.0 

Etheris  sulph ..30.0 

Apply  with  gentle  friction. 

FOR  DIFFUSE  ALOPECIA. 

1.  Tinct.  cantharidis 5.0 

Tinct.  jaborandi, 

Spts.  melissse aa     15.0 

Spts.  odorati 65.0 

2.  Aq.  ammonia  fort 2  to  5.0 

Liq.  picis  alkalini, 

Spts.  camphor aa     15.0 

Alcohol,  60  per  cent 70.0 

3 .  Quininse  muriat 10 

Tinct.  jaborandi 20.0 

Spts.  ajtheris 80.0 

01.  verbense Q-  s- 


744  APPENDIX 

The  last  mentioned  stimulating  lotions  are  applied  on  the  scalp  by 
means  of  a  small  so-called  "lotion-brush."  The  formulas  can  be 
easily  modified  by  incorporating  into  them,  if  indicated,  one  or 
other  of  the  reducing  agents  in  use  for  the  hairy  regions. 

10.  ANTIPARASITICS. 

Vegetable  Parasites. — The  destruction  of  the  epidermophytes  is 
usually  easy  on  the  hairless  skin  (cf.  pp.  519,  524,  520,  529,  531). 

All  the  detergent  remedies  and  strong  antiseptics  may  be  utilized, 
such  as  soft  soap,  naphthol,  phenol,  mercurial  salts  in  solutions  or  in 
strong  salves.  The  present  preference  is  for  iodine  treatment  with 
the  tincture  (1  :  20  to  50)  or  in  a  vaseline  salve  (1  :  100)  or  for 
chrysarobine  in  weak  salves  (1  :  300  to  1  :  3000).  [For  epidermo- 
phytoses of  the  hands  and  feet,  Whitfield's  salve  (ac.  salicyl  1.0, 
ac.  benzoic  2.0,  adipis  benz.  12.0)  is  especially  to  be  recommended.] 

In  case  of  tinea,  chrysarobin  salve-sticks  may  also  be  employed 
(chrysarobin  10  to  30  gr.,  yellow  wax  20  to  40,  adeps  lana?  50)  or 
according  to  the  formula  give  above. 

The  employment  of  chrysarobin  on  the  head,  in  strong  salves, 
or  especially  in  plasters,  requires  great  caution  on  account  of  the 
highly  irritative  action  of  this  remedy  on  the  conjunctiva^. 

After  epilation  (by  .r-ray)  it  is  advisable  to  rub  the  scalp  with 
dilute  tincture  of  iodine,  or  with  carbolized  glycerine  (1  :  50). 

Animal  Parasites. — Pediculosis. — According  to  the  conditions 
of  the  environment  and  other  factors  a  choice  should  be  made 
between  the  following  remedies: 

Powders. — Naphthaline  mixed  with  talc  (50  :  100) ;  N.  C.  I.  mixture 
of  the  British  Army  (naphthalene  96,  creosote  2,  iodoform2). 

Liquids  for  Washes,  Sprays  or  Sachets. — Benzine,  xylol,  petroleum, 
turpentine  oil  (15  :  1000),  camphorated  oil  (10  :  100),  spirits  of 
camphor,  carbolized  water  (2  :  100),  chloroform  water;  vinegar 
with  sublimate  (1  :500);  parasiticide  wash  of  the  Hopital  Saint- 
Louis  (sublimate  1,  spirits  of  turpentine  130,  glycerine  170,  cam- 
phorated alcohol  700);  cresyl  solutions  (for  example:  paracresylol 
or  sapocresol  30,  almond  soap  15,  water  1000,  Choay). 

Recently,  various  products  derived  from  cresol  have  been  recom- 
mended, as  well  as  various  volatile  oils,  for  example: 

SOLUTION  FOR  SPRAYS. 

Anisol  (methyl-phenol) 0.03  to  0.05 

Denatured  alcohol, 

Water aa     50.0 

Kills  lire  in  eight  to  ten  minutes;  to  be  employed  several  days  in  succession. 


antiparasitics  745 

PARASITICIDE  MIXTURE  (LEGROUX) . 
01.  citronellae, 
01.  menthse  pip., 

01.  eucalypti  glob aa  300.0 

Naphtalin  pulv 100.0 

To  be  used  in  "sachets,"  or  in  dilute  alcoholic  solution  (5  to  100)  as  a  wash. 

Disinfection  of  clothing  and  bedding  in  the  steam-sterilizer  is  of 
great  importance;  shaving  of  the  head  and  body  hairs,  when  prac- 
ticable, as  well  as  ironing  the  clothes  with  a  hot  iron,  are  to  be 
recommended. 

Salves. — These  may  be  prepared  from  a  large  number  of  the  above- 
mentioned  remedies.  I  repeat  that  I  have  found  yellow  mercury 
salve  most  efficient  and  harmless  in  the  treatment  of  phthiriasis 
inguinalis  (yellow  oxide  of  the  Hg.  10,  oxide  of  zinc,  10,  salicylic 
acid  and  resorcin  aa  1,  vaseline  78.) 

Scabies. — There  is  an  abundance  of  formulas;  the  majority  are 
based  on  sulphur. 

Balsam  of  Peru  and  styrax  ointment  are  also  excellent  against 
the  itch  and  may  be  employed  pure  or  incorporated  in  vaseline,  or 
dissolved  in  alcohol  with  an  addition  of  castor  oil. 

HOPITAL  SAINT  LOUIS  FORMULA. 

Sulphur,  sublimat 20.0 

Potass,  carbonat 8.0 

Aq.  destil 8.0 

Adipis 64.0 

HELMERICH-HARDY  SALVE. 

Sulphuris  nor 20.0 

Potass,  carbonat 10.0 

120.0 


VLEMINCKX'  SOLUTION. 

Sublimed  sulphur 250.0 

Quicklime   .      .      . 150.0 

Water 2500.0 

Boil  down  to  1500. 

WILKINSON-HEBRA  SALVE. 
01.  Rusci, 

Sulphur,  sublimat aa     10.0 

Saponis  viridis, 

Adipis aa     20.0 

Cretse  pulv 5.0 

BOURGUIGNON'S  SALVE. 

01.  lavandulse,  cinnamonii, 

Menthse  pip.,  caryophyl '.      .      .      .   aa       2.0 

Tragacanth 4.0 

Potass,  carbonat .30.0 

Flor.  sulphur 90.0 

Glycerini 180.0 


746  APPENDIX 

PERU  BALSAM  SALVE. 

Bals.  Peruv 15.0 

Styracis  liq 20.0 

Cretse  prsep 20.0 

Adipis  (or  petrolati) 45.0 

With  the  two  last  named  salves,  disinfection  of  the  clothing  is 

said  to  be  not  absolutely  necessary  but  the  bedding  must  be  dis- 
infected. 

[Sherwell's  method  is  simple  and  effective:  The  patient,  stripped 
and  in  bed,  rubs  himself  vigorously  every  night  with  the  dry  powder 
of  flowers  of  sulphur  (sulphur  sublimatum),  leaving  the  spilled 
powder  between  the  sheets  and  under  the  night-clothes.  The  cure 
requires  about  a  week.  It  has  the  merit,  of  simplicity  and  great 
economy,  especially  where  an  entire  family  has  to  be  disinfected. 1 

11.  CAUSTICS. 

The  employment  of  caustics  for  the  destruction  of  small  tumors, 
proliferations  and  nevi,  is  becoming  more  and  more  restricted;  the 
preference  is  accorded  to  the  galvano-cautery,  superheated  air  and 
carbonic  acid  snow,  the  action  of  which  is  instantaneous  and  more 
easily  graduated. 

Use  is  still  sometimes  made,  however,  of  the  following:  nitric, 
hydrochloric,  lactic,  trichloracetic,  chromic,  arsenious  acids;  caustic 
potash;  zinc  chloride,  corrosive  sublimate,  acid  nitrate  of  mercury, 
pure  phenol,  resorcin,  pyrogallol,  permanganate  of  potash,  etc. 
Ordinary  formalin  has  been  recommended  for  the  destruction  of 
proliferations. 

Arsenious  acid  is  the  remedy  of  choice  for  epitheliomas,  in  suspen- 
sion in  a  liquid  rather  than  in  the  form  of  a  paste. 

CZERNY-TRUNECEK  SOLUTION. 

Arsenic  triox 1-0 

AquEe, 

Alcohol  (90  per  cent.) aa     50.0 

Shake.    For  method  of  use  see  p.  688. 

ARSENICAL  POWDER. 

Arsenic  triox 1.0 

Carbonis  ligni  pulv 2.0 

Hydrarg.  sulph.  rubri 5.0 

Mix  with  a  little  mucilage. 

canquoin's  paste  (carbuncle). 

Zinci  chloridi 8.0 

Zinci  oxidi 2.0 

Amyli  tritici 6.0 

A«i.  dest 1.0 

Make  a  paste. 


DIET  747 

VIENNA  PASTE. 

Potassii  hydrox 5.0 

Calcis  ustse       .  6.0 

Before  use,  make  a  paste  by  moistening  with  alcohol. 

Silver  nitrate  has  only  a  very  superficial  action.  It  is  often  em- 
ployed in  pencils  or  in  watery  or  alcoholic  solutions  (1  :  10  to  30) 
on  mucous  patches,  erosions  and  for  the  control  of  exuberant  granu- 
lation of  wounds. 

Its  action  can  be  considerably  strengthened  by  the  so-called 
"two  pencil"  procedure:  the  surface  which  has  been  cauterized  with 
silver  nitrate  is  passed  over  with  a  pointed  pencil  of  metallic  zinc. 
This  procedure  is  serviceable  for  example  in  cases  of  ulcerated  lupus. 

I  have  often  advantageously  utilized  the  following  caustic  pastes, 
advocated  by  Unna : 

GREEN  PASTE  (LUPUS  VULGARIS). 

Antimonii  trichlorid. 

Ac.  salicylic aa       2.0 

Creosoti  (Beechwood), 

Ext.  cannabis  Ind aa       4.0 

Lanolin 8.0 

WHITE  CAUSTIC  PASTE  (TUBERCULOSIS  VERRUCOSA). 

Caustic  potash, 

Quicklime, 

Green  soap, 

Distilled  water aa       5.0 

Apply  over  the  lupus  or  verrucous  patch,  by  means  of  a  spatula, 
a  layer  of  paste  about  the  thickness  of  a  knife-blade;  wipe  off  the 
edges  with  cotton;  cover  with  a  large  piece  of  zinc  oxide  plaster. 
In  case  of  the  white  paste,  it  is  advisable  to  interpolate  a  wad  of 
moist  cotton  between  the  caustic  and  the  plaster.  The  pain  is 
never  excessive  and  does  not  last  long.  At  the  end  of  a  few  hours 
the  plaster  is  removed  and  moist  dressings  are  applied.  In  case  of  the 
green  paste,  the  applications  are  repeated  twice  a  week  on  an  aver- 
age, until  total  destruction  of  the  diseased  tissue  has  been  accom- 
plished. 

I  have  found  these  preparations  preferable  to  cauterizations  with 
pyrogallol,  resorcin  in  strong  salves,  or  potassium  permanganate 
in  concentrated  solution  or  as  a  powder,  which  are  employed  by 
others. 

12.  DIET. 

It  would  be  altogether  erroneous  to  assume  that  there  is  an 
alimentary  regimen  applicable  to  all  cutaneous  diseases.  Nor  is  it 
a  given  eruption  which  governs  the  diet,  but  rather  the  general 


748  APPENDIX 

nutritional  disturbance  of  which  it  may  be  a  direct  expression  or  an 
indirect  consequence  or  which  may  create  a  predisposition  to  that 
particular  eruption. 

In  a  patient  suffering  from  a  skin  disease,  the  demonstration  of 
diabetes,  anemia,  "lymphatic"  constitution,  gastro-intestinal  dys- 
pepsia or  enteritis,  hepatic  or  renal  insufficiency,  nervousness,  or 
an  intoxication  or  chronic  auto-intoxication,  etc.,  necessitates  in 
itself  the  appropriate  diet,  such  as  laid  down  in  text-books  of  general 
medicine. 

Another  point  which  must  be  thoroughly  considered  is  the  exist- 
ence of  infinitely  variable,  practically  unlimited  and  often  entirely 
unexpected  individual  sensibilities  and  idiosyncrasies  of  intolerance 
toward  many  articles  of  food  and  drink.  It  is  therefore  advisable 
to  make  it  a  rule  never  to  ignore  the  statements  of  patients  in 
regard  to  their  intolerance  of  a  given  alimentary  substance;  on  the 
contrary,  care  should  be  taken  to  guide  their  observations  in  this 
direction,  while  realizing  that  persons  capable  of  trustworthy  self- 
observation  are  in  a  great  minority,  as  pointed  out  by  Jadassohn. 

All  dermatologists  have  encountered  patients  who  attribute  their 
attacks  of  erythema,  urticaria,  pruritus  or  eczema,  to  the  ingestion 
of  strawberries,  mussels,  game,  pork,  or  champagne;  others  hold 
milk,  eggs,  spinach,  veal,  etc.,  responsible.  Although  the  available 
information  on  the  subject  of  anaphylaxes  is  of  a  kind  to  furnish  the 
explanation  for  a  certain  number  of  cases,  the  physician  is  justified 
in  remaining  unconvinced  until  a  positive  demonstration  has  been 
made. 

At  an}'  rate,  it  would  be  unreasonable  and  exaggerated  to  forbid 
to  all  patients  what  may  have  harmed  a  few;  this  would  result  in 
the  prescribing  of  an  over-rigid  and  more  or  less  impracticable 
diet. 

The  physician  may  sometimes  find  it  necessary  to  recommend 
for  a  time  an  exclusive  regimen  such  as  an  absolute  milk  diet,  or 
a  purely  carbohydrate  regimen,  permitting  only  successively  the 
addition  of  various  kinds  of  foods  and  drinks;  through  this  pro- 
cedure, which  is  logical  and  to  be  recommended,  one  may  hope  to 
trace  the  idiosyncrasy  of  the  patient.  It  is  always  advisable  in  such 
cases  to  be  on  one's  guard  against  unintentional  departures  from  the 
regimen  and  against  fraud. 

[Some  knowledge  of  cookery  is  a  very  useful  acquisition  on  the 
part  of  the  physician.  In  excluding  milk  and  eggs,  for  instance,  it 
must  be  remembered  that  these  articles  enter  into  many  prepara- 
tions of  food,  various  sauces,  most  pastries,  etc.] 

After  these  general  statements,  I  am  adding  a  list  of  the  beverages 
and  foods  which  are  often  found  to  be  injurious  to  patients  suffer- 
ing from  hyperemic  or  pruritic  dermatoses  {erythemas,  urticarias, 


DIET  749 

eczemas,  neurodermatitis,  lichen  planus,  etc.),  and  which  it  is 
customary  to  prohibit  more  or  less  strictly. 

Alcoholic  beverages  in  general  (especially  unmixed  wine,  cham- 
pagne, liqueurs,  bitters,  medicated  wines,  strong  beers,  cider),  as 
well  as  coffee,  tea  and  chocolate. 

High  meats  and  conserves  (game,  smoked  meats,  salted  meats, 
sausages,  meat-pies,  ragouts,  galantines,  foie  gras) ;  certain  meats, 
such  as  pork,  duck,  veal. 

Deep-sea  fish,  smoked  or  salted  fish,  crabs,  lobsters  and  shellfish. 

Vegetables:  Sorrel,  spinach,  tomatoes,  stringbeans,  asparagus, 
cabbage,  cauliflower,  "sour  krout,"  cucumbers,  mushrooms, 
truffles,  raw  salads. 

Fruits:  Strawberries,  raspberries,  gooseberries,  melons,  nuts 
and  figs. 

All  cheeses,  except  fresh  non-fermented  and  salted  cheese.  Sweet- 
meats and  pastries. 

In  a  general  way,  all  condiments,  vinegar,  spices,  mayonnaise 
dressings,  tartare  sauces,  mustard,  etc. 

This  list  will  be  seen  to  comprise  among  others:  (1)  Substances 
possessing  stimulating  or  irritative  properties  (alcohol,  tea,  coffee, 
spices) ;  fermented,  changed  substances  or  those  suspected  of  being 
so  on  account  of  their  liability  to  change  and  containing  toxins  (high 
meats  and  venison,  meat-conserves,  deep-sea  fish) ;  foods  of  difficult 
digestion  (salads,  raw  substances). 

It  goes  without  saying  that  restrictions  or  prohibitions  must  be 
rendered  with  tactfulness  and  discrimination,  adapting  them  not 
only  to  the  pathological  conditions  of  the  case  but  up  to  a  certain 
degree  to  the  social  standing  of  the  patient.  The  diet  must  be 
individualized,  like  all  therapeutic  prescriptions.  Suggestions  in 
this  respect  may  be  drawn  from  the  few  general  directions  which  I 
have  summarized  in  discussing  the  treatment  of  eczema. 

[The  divergence  among  competent  dermatologists  on  so  appar- 
ently simple  a  question  as  the  value  of  a  non-nitrogenous  diet  in 
psoriasis  and  some  other  dermatoses  is  certainly  remarkable  and 
suggestive.  In  regard  to  urticaria,  oedema  circumscriptum  and 
similar  affections  which  seem  to  be  typical  of  an  anaphylactic  dis- 
turbance, how  often  does  the  most  rigid  inquest  fail  to  disclose  the 
peccant  alimentary  or  autotoxic  substance!  The  recently  introduced 
"cutaneous  tests"  that  in  theory  seemed  so  promising  have  proved 
disappointing  in  practice.] 

In  conclusion,  I  consider  it  necessary  to  emphasize  once  again  the 
importance,  which  I  regard  as  very  great,  of  ascertaining  the  con- 
dition of  the  teeth  (notably  in  erythrosis,  in  many  eczemas  and 
pruriginous  dermatoses,  in  alopecia,  etc.  Dental  caries,  or  the  loss 
of  a  large  number  of  teeth,  an  abundance  of  tartar,  pyorrhea  alveo- 


750  .1 PPENDIX 

laris,  inflammations  of  the  gums  or  gingivitis  are  certainly  the  start- 
ing-point not  only  of  reflex  disturbances  but  also  of  a  real  chronic 
intoxication.  The  latter  is  the  effect  either  of  the  constant  swallow- 
ing of  putrid  products  and  pus,  at  all  hours  of  the  day  and  night;  or 
of  the  arrival  in  the  stomach  of  imperfectly  masticated  and  poorly 
insalivated  food;  the  latter,  not  being  in  a  condition  to  undergo  in 
a  proper  way  the  action  of  the  digestive  juices,  will  permit  and  favor 
abnormal  gastro-intestinal  fermentations. 

After  having  experienced  it  on  repeated  occasions,  I  am  now 
convinced  that  putting  the  teeth  in  good  condition,  wearing  a 
suitable  artificial  denture,  with  proper  care  of  the  mouth,  can 
powerfully  contribute  to  the  inhibition  of  eruptive  attacks,  to  the 
improvement  of  the  general  condition  of  many  patients;  while 
permitting  the  cure  of  skin  diseases  which  had  before  resisted  even 
correct  topical  applications  as  well  as  the  prescription  of  a  Draconian 
alimentary  regimen. 


INDEX 


Abscess,  miliary,  of  little  children, 
Abscesses  of  axilla,  tuberous,  544 
Acant  holysis,  174 
Acanthosis,  64 

nigricans,  242 
Acarophobia,  482 
Achromia,  320 
Achromic  nevi,  320 
Acne,  bromide,  476 

cachecticorum,  385,  567 

cornea,  385 

decalvans,  385,  394 

frontalis,  391 

hypertrophica,  374,  385 

iodide,  475 

juvenilis,  385 

keloid,  391 

lupoid,  394 

medicinal,  390 

miliaris,  385 

necrotica,  391 

occupational,  390 

papularis,  386 

phlegmonous,  386 

pilaris,  391 

polymorphous,  386 

punctata,  386 

pustular,  superficial,  386 

rodens,  391 

rosacea,  36,  385 

rosea,  36 

sebacea,  383,  385 

syphilitica,  385 

telangiectodes,  566 

treatment  of,  388 

tuberosa,  386 

variohformis,  385,  391 

vulgaris,  385 
Acne,  cornee.  403 

"sebacce,"  209 
Acneiform  eczema,  90 

lupus,  570 

peripilar  syphilid  es,  396 

syphilides,  398 

tuberculides,  564 
Acnes.  384 
Acnitis,  398,  567 
Acro-asphyxia,  36 


446 


Acrodermatitis    atrophicans    chronica , 
344 

continuous,  186,  216 
Acrokeratoma,  212 
Actinomyces,  599 
Actinomycosis,  270,  599 
Acute  circumscribed  edema,  49 
Addisonian  melanodermas,  325 
Adeno-lymphocele,  364 
Adenoma  sebaceum,  672 
Adenomata,  672 
Adenomatous  nevi,  672 
Albinism,  320 
Alcoholic  solutions,  714 
Aleppo  boil,  648 
Alimentary  eruptions,  479 
Allergy,  548 
Alopecia  atrophicans,  393 

parrimaculata,  393 

pseudo-favic,  394 
Alopecias,  407 

achromatous,  413 

areata,  413 

cicatricial,  412 

circumscribed,  412 

coronarius,  413 

decalvans,  413,  414 

diffuse,  408 

of  general  disease,  411 

kerotic,  408 

non-cicatricial,  412 

pathological,  408 

pellicular,  409 

pityroid,  409 

premature,  409 

regional,  408 

seborrheic,  409 

senile,  409 

syphilitic,  411 

totalis,  413 

traumatic,  408 

treatment  of,  415 

with  fragile  hairs,  413 
Alopecic  favus,  421 
Anal  pruritus,  488 
Anaphylaxis,  460 
Anatomical  tubercle,  552 
Anesthetics,  local,  729 
Anetoderma  erythematosum  of  Jadas- 
sohn, 345 


752 


INDEX 


Angina,  herpetic,  152 

Vincent's,  306 
Angiohematic  typhus,  57 
Angiokeratoma,  ol>4.  tilt.") 
Angiokeratotic  tuberculides,  5(34 
Angioma,  693 

flat,  693 

progressive  multiple,  694 

senile,  695 

stellate,  695 

tuberous,  693 
Angiomatous  Lupus,  554 
Angiosarcoma,  707 
Anidrosis,  442 
Annamite  ulcers,  301 
Annular  syphilide,  144 
Anonychia,  431 
Anthrax,  593 
Anti-anaphylaxis,  461 
Antiparasitics,  743 

for  animal  parasites,  744 

for  pediculosis,  744 

for  scabies,  745 

for  vegetable  parasites,  743 
Antiphlogistics,  718 
Antipruritic  agents,  727 
Antipyrin  bulla?,  177 
Antipyrinides,  473 
Antiseptics  and  astringents,  722 

strong,  726 
Aphtha?,  306 
Aplasia  laminaris,  354 

moniliformis,  418 
Arciform  syphilide,  144 
Argas,  514 
Argyria,  332 
Arsenical  dyschromias,  328 

keratosis,  213 

treatment  of,  661 
"Arthritide  bulleuse,"  179 
Arthritism,  479 
Arthropathic  psoriasis,  105 
Artificial  dermatitides,  447,  467 

eczema,  79 

pigmentations,  321 

pruritus,  482 
Aspergillus,  599 

lapidophyton,  528 
Atrophic  dermatoses,  335 

lichen  planus,  137 
Atrophies,  cicatricial,  339 

cutaneous,  334 

idiopathic,  343 

linear,  341 

macular,  341,  345 

postsyphilitic,  342 

regional,  353 

reticular,  344 

round,  342 

sclerotic,  in  spots,  346 
Atrophoderma,  334 

pigmentosum,  355 


Autotoxic  eruptions,  479 

erythemia,  28 

urticaria,  46 
Axilla,  abscess  of,  tuberous,  544 


B 


Bai.axoposthitis,  circinate  erosive,  311 
Balsamic  erythemas,  473 
Barlow's  disease,  55 
Baso-cellular  epithelioma,  679 
Bazin,  acne  pilaris  of,  391 

erythema  induratum  of,  274 

pathogenic  erythema  of,  27 
Bazin's  hydroa,  176 
Beard,  eczema  of,  74 
Beauty  spots,  664 
Bed-bugs,  506 
Biett,  collarette  of,  626 
Biopsic  pruritus,  487 
Birthmarks,  664 
Biskra  boil,  648 

button,  250 
Black  tongue,  229 
Blastomycoses,  603 

Busse-Buschke  type  of,  603 

Gilchrist  type  of,  603 
Blastomycosis,  270 
Bleaching  agents,  733 
Blisters,  175 

Blood,  diseases  of,  dyschromias  in,  328 
Bockhardt,  impetigo  of,  167 
Body-lice,  504 

Boeck,  acne  necrotica  of,  391 
Boils,  540 

Botryomycoma,  704 
Boubas,  650 

Bowen,  precancerous  dermatosis  of,  236 
Brocq,  lupoid  sycosis  of,  394 

pseudo-pelade  of,  393 
Bromide  acne,  476 
Bromidrosis,  443 
Bromoderma  tuberosum,  476 
Bubo,  syphilitic,  612 
Buccal  cavity,  neoplasms  of,  ulcerative, 
309 

diphtheria,  305 

gangrene,  308 

herpes,  304 

hydroa,  304 

ichthyosis,  219 

mucosa,  erosions  of,  diphtheroid, 
304 
ulcerations  of,  304 

pemphigus,  304 

pruritus,  488 

psoriasis,  219 

zona,  304 
Bulla?,  174 

acant  holy  tic,  174 

antipyrine,  177 


INDEX 


753 


Bulla?,  deep,  174 

purulent,  174 

subcorneal,  174 

subepithelial,  174 

superficial,  l74 

traumatic,  175 
Bullous  dermatoses,  174 
accidentally,  175 

erythema,  24 

impetigos,  178 

polymorphous  erythema,  175 

syphilides,  177,  620 

toxicodermas,  177 

urticaria,  45,  175 
Burns,  450 

of  first  degree,  451 

of  second  degree,  451 

of  third  degree,  451 
Buttock,  herpes  of,  153 


Cachetic  ecthyma,  170 

purpura,  54 
Cachexias,  dyschromias  in,  328 
Cacotrophia  folliculorum,  402 
Calcareous  tumors,  692 
Calcified  epithelioma,  679 
Callositas,  449 
Callus,  449 
Calvities,  408 

hippocratica,  409 
Calymmato-bacterium      granulomatis, 

251 
Canaliculitis,  310 
Cancer,  green,  653 
Cancers,  epithelial,  676 
Cancroid  epithelioma,  677 
Cancroids,  676 
Canities,  416 
Carafes,  528 
Carbolic  gangrene,  314 
Carbunculus,  543 
Carcinoma,  secondary,  683 
Carrion's  disease,  593 
Caustics,  746 
Cellular  nevi,  666 
Cervical  zona,  156 
Chalazoderma,  372 
Chancre,  dwarf,  615 

ecthymatous,  615 

extragenital,  616 

genital,  616 

giant,  615 

hard,  613 

hypertrophic,  615 

incipient,  597    . 

mature,  597 

miliary,  597 

mixed,  283 

papular,  597,  615 
4S 


Chancre  redux,  615 

simple,  596 

soft,  281,  596 

extragenital,  282 

of  genital  mucosa,  316 

syphilitic,  613 

of  genital  mucosa,  311 
of  mouth,  307   ■ 

ulcerative,  615 
syphilitic,  283 
Chancroid,  281,  596 
Chancroidal  folliculitis,  597 

phagedena,  295 
Cheiropompholyx,  85 
Chilblains,  34 
Chloasma,  324 
Chloroma,  653 
Chlorotic  pemphigus,  192 
Chromatorrhexis,  591 
Chromidroses,  444 
|  Cicatrices,  336 
Cicatricial  alopecias,  412 

atrophies,  339 

depilating  folliculitides,  392 

epithelioma,  flat,  681 

folliculitis  of  hairless  parts,  566 
Cicatrizing   and  keratoplastic   agents, 

740 
Circinate  erosive  balanoposthitis,  311 
Circumscribed  alopecias,  412 

keratoses,  206 
Clavus,  449 

Cleansing  and  keratolytic  agents,  730 
Cohnistreptothrix,  599 
Collarette,  of  Biett,  626 
Colloid  milium,  359,  692 
Colored  sweats,  444 
Comedo,  385 

Condyloma  acuminatum,  238 
Congenital  elephantiasis,  361,  370 

erythrodermas,  122 

hyperkeratosis,  203 
diffuse,  124 

ichthyosis,  124 

macroglossia,  370 

malformations  of  nails,  431 

malignant  keratoma,  diffuse,  124 

pemphigus,  191 

syphilis,  624 

precocious,  625 

xanthoma,  699 
Conjunctiva,  herpes  of,  153 
Connective-tissue  tumors,  689 
Contusiform  dermatitis,  265 
"Copper-nose,"  374 
Corns,  449 

Cornu  cutaneum,  677 
Corona  veneris,  144 
Couperose,  36 
Crab-louse,  505 
"Crasse  des  vieillards,"  209 
Creams,  717 


INDEX 


< Iretinism,  372 

(  rvptococcus,  599 

( '\itis  hvperelastica,  372 

laxa,  372 
( !ylindroma,  682 
( 'vstic  follicular  adenomatous  nevi,  071 

sudoriparous  adenomata,  672 
( Systicercus  cellulosse,  515 
Cysts,  670 

dermoid,  671 

epidermic,  670 

traumatic,  671 

follicular,  671 

sebaceous,  670 

scnms,  672 


Darier's  disease,  231 

Date-boil,  648 

Degeneration,  senile,  357 

Delhi  boil,  648 

Demodex  folliculorum,  513 

Depapillated  plaques  of  tongue,  304 

Dermatitides,  artificial,  447,  467 

due  to  mechanical  causes,  448 
physical  causes,  450 

induced,  467 

occupational,  467 

simulated,  471 

traumatic  eczematiform,  SO 
Dermatitis,    acute    benign    exfoliating, 
116 

artefaeta,  183 

atrophicans,  343 

contusiform,  265 

exfoliating,  117 

of  nurslings,  123 

gangrenous,  of  children,  317 

generalized  exfoliative,  117,  US 

herpetiformis,  17(1 

papillaris  capillitii,  391 

polymorphous,  179 

sycosiformis  atrophicans,  394 

vacciniform,  infantile,  168 

venenata,  470 
I  termatolyses,  372 
1  )ermatomycoses,  599 

ulcerations  of,  293 
Dermatophobia,  482 
Dermatophytes,  502 
Dermatoscleroses,  334,  353. 
I  >ermatoses,  atrophic,  335 

bulbous,  174 

accidentally,  175 

caused  by  acari   (mites),  507 
by  insects,  502 
by  worms  and  larva?,  514 

dyschromic,  323 

eruptive,  17 

erythematous-squamous,  89 

erythrodermic,  120 


Dermatoses,  hypertrophic,  361 

infectious,  535 

liacillary,  546 

chronic,  pustules  of,  172 

due  to  protozoa,  610 

of  leukemias,  651 

nodular,  263 
acute,  265 

non-eruptive,  IS 

nosology  of,  447 

onychoses  of,  434 

papillomatous,  238 

papular,  127 

parasitic,  502 

pigmentary,  of  legs,  323 

precancerous,  of  Bowen,  236 

proliferating,  accidentally,  244 

pustular,  161 

sclerotic,  335 

tropical  proliferating,  249 

tuberculo-ulcerative,  253 

ulcerative',  2S1 

vesicular,  149 
Dermic  gummas,  267 

papules,  128 

pustules,  160 
Dermographism,  49 
Dermoid  cysts,  (571 
Desquamation    of    newborn,    lamellar, 

122 
Desquamative  erythema,  24 

erythroderma  of  nurslings,  124 
Diabetic  eruptions,  480 

gangrene,  316 

xanthoma,  699 
Diabetides,  genital,  480 
Diathetic  pruritus,  484 
Diet,  747 
Diffuse  congenital  hyperkeratosis,  124 

malignant  keratoma,  124 
Diphtheria,  buccal,  305 

cutaneous,  594 
Diphtheroid  erosions  of  buccal  mucosa, 
304 

pemphigus,  187 

stomatitis,  305 
Discomyces  minutissimus,  533 
Disseminated  miliary  lupoid,  259 

pigmentary  spots,  325 
1  >racunculus,  ."ill 
Dry  eczema,  63,  72 

erosions  of  tongue,  304 
Duhring's  disease,  17!) 

rare  dermatoses  related  to,  184 
Dwarf  chancre,  615 
Dyschromias,  320 

arsenical,  32S 
artificial,  321 

associated,  323 
in  cachexias,  328 
diffuse,  325 


INDEX 


755 


Dyschromias  in  diseases  of  blood,  328 

of  leprosy,  327 

of  nervous  diseases,  327 

secondary,  321 
Dyschromic  dermatoses,  323 
Dyscratic  pruritus,  484,  487 
Dysidrosis,  85 
Dysidrotic  eczema,  86 
Dyskeratoses,  194,  230 

follicularis,  231 

lenticularis  et  discoides,  236 
Dystrophic  onychoses,  437 

trichoses,  416 
Dystrophies,  cutaneous,  355 
Dystrophy,  papillary,  242 

pigmentary,  242 
le,  358 


E 


Ecchymoses,  52 
Ecthyma,  169,  284 

cachetic,  170 

gangrenous,  317 

scrofulous,  170 

syphilitic,  170 

terebrans,  171 

scrofulosorum,  568 
Ecthymatous  chancre,  615 
Eczema,  60 
Eczema,  acneiform,  90 

acute  disseminated,  87 

artificial,  79 

of  beard,  74 

between  toes,  75 

corneal,  214 

dry,  63,  72 

dysidrotic,  86 

erysipeloid,  71 

exudative,  71 

of  face,  75 

fissured,  71 

flanellaire,  92 

folliculorum,  396,  564 

of  forearms,  75 

generalized,  120 

of  hairy  regions,  74 

of  hands,  75 

hyperkeratotic,  64 

impetiginous,  64,  71,  72 

infantile,  65,  80 

infected,  64 

intertrigo,  of  infants,  75 

keratotic,  72,  214 

lamellar,  64 

of  legs,  75 

lichenified,  71,  72 

lichenoid,  64 

marginatum,  74,  90 
of  Hebra,  524 

microbic,  66 


Eczema  of  nails,  435 

of  nipple,  75 

nummular,  72 

occupational,  65 

orbicular,  75 

orificial,  75 

papulo-vesicular,  72 

parasitic,  65 

paratraumatic,  66,  73 

pilaris,  379 

psoriasis,  104 

psoriatiform,  64 

rubrum,  64,  71 

of  scalp,  74 

scrofulosorum,  147 

seborrheal,  63 

seborrhceicum,  90 

secondary,  87 

senile,  65 

solare,  65 

squamous,  64,  72 

traumatic,  from  scratching,  65 

treatment  of,  77 

true,  83 

tylotic,  72 

varicose,  73 

vesicular,  71 

vulgare,  72 

of  war  wounds,  66,  73 

weeping,  63 

of  wrists,  75 
Eczematides,  90 

erythrodermic,  95 

figured,  92 

follicular,  395 

peripilar,  95 

pityriasiform,  93 

psoriatiform,  95 
Eczematization,  60 
!  Eczematoid  tuberculides,  564 
Eczematosis,  60,  83     * 
Edema,  acute  circumscribed,  49 

malignant,  594 
Edematous  scleroderma,  347 
Elastoma,  359 
Elastorrhexis,  359 
Electric  erythema,  32 
Elephantiasis,  361 

arabum,  361 

congenital,  361,  370 

filarial,  361,  369,  515 

grsecorum,  361,  578 

nostras,  361,  367 

papillomatous,  246 

secondary,  361,  368 

verrucous,  246 
Elephantiastic  lupus,  554 
Emotional  erythema,  28 

roseola,  25 
Endodermophytons,  528 
Ephelides,  323 
Ephidrosis,  443 


756 


INDEX 


Epidermic  cysts,  670 

traumatic,  671 

nail,  431 

papules,  127 

pemphigus  of  newborn,  168 

pustules,  161 
Epidermolysis  hereditaria  bullosa, 
Epidermomycoses,  515 
Epidermophytes,  515 
Epidermophytosis,  114,  216,  522 
Epiphenomena,  175 
EpitheUal  cancers,  676 

tumors,  669 
Epithelioma,  676 

baso-eellular,  679 

of  buccal  cavity,  309 

calcified,  679 

cancroid,  677 

cellular,  676 

flat  cicatricial,  338,  681 

metastatic,  683 

nevo-cellular,  682 

pagetoid,  681 

papillary,  677 

papillomatous,  249 

proliferating,  249 

spinocellular,  676 

terebrans,  682 

treatment  of,  687 

tubular,  679 

proliferative,  682 
Epitheliomatosis  pigmentosa,  355 
Epizoa,  502 
Equine  scabies,  120 
Ergotism,  316 
Erosions  of  tongue,  304 
Erosive  ulcers,  676 
Eruptions,  alimentary,  479 

autotoxic,  479 

diabetic,  480 

feigned^  471 

medicinal,  463,  472 

serum,  477 

toxic,  472 
Eruptive  dermatoses,  17 

xanthoma,  698 
Erysipelas,  gangrenous,  319 
Erysipeloid  eczema,  71 
Erythema,  23 

active,  24 

of  alimentary  origin,  27 

annulare,  26 

associated,  23 

atrophicans,  343 

autotoxic,  28 

balsamic,  473 

bullous,  24 

centrifugum,  570,  571 

desquamative,  24 

emotional,  28 

figured,  25 

a  i'rigore,  27 


Erythema  induratum,  564 
of  Bazin,  274 
of  young  girls,  25 

infantile  gluteal.  31 

infectious,  27,  28 

intertrigo,  27 
191  marginatum,  26 

multiforme,  39 

nodosum,  265 

nodular,  24 

papular,  24 

papulo-erythematous,  39 

papulo-lenticular,  31 

passive,  24 

in  patches,  25 

pathogenic,  of  Bazin,  27 

pellagrous,  32 

pernio,  34 

perstans,  26,  572 

pigmented,  24 

polymorphous,  bullous,  175 

a,  pudore,  28 

purpuric,  24 

recurrent  desquamative  scarlatini- 
form,  25,  116 

reflex,  28 

rubeoliform,  25 

scarlatiniform,  25 

scarlatinoid,  25 

simple,  24 

solare  seu  actinicum,  32 

squamous,  24 

treatment  of,  426 

urticarial,  24 

vesicular,  24 
Erythemato-atrophic  tuberculides,  564 
Erythemato-follicular  lupus,  570 
Erythemato-papular  syphilides,  142 
Erythemato-squamous  dermatoses,  89 
Erythemato-squamous     epidermo-my- 

coses,  114 
Erythemato-tuberculous  lupus,  555 
Erythematoid  lupus,  228,  554 
Erythematous  syphilides,  620 

tuberculides,  564 
Erythrasma,  114,  532 
Erythroderma,  ichthyosiform,  203 
Erythrodermas,  23,  115 

congenital,  122 

desquamative,  of  nurslings,  124 

leukemic,  119 

of  newborn,  122 

premycotic,  119 

primary,  116,  117,  118 

secondary,  120 
Erythrodermic  dermatoses,  120 

eczematides,  95 

tuberculides,  564 
Erythromelia,  344 
Erythrosis  facialis,  37 
Espundia,  650 
Esthiomene,  311 


INDEX 


757 


Ethereal  solutions,  714 
Excoriation  of  tongue,   chronic  super- 
ficial, 229 
Exfoliative  areata,  228 

dermatitis  of  nurslings,  123 
Extragenital  chancre,  282,  616 
Exudative  eczema,  71 


Face,  eczema  of,  75 

herpes  of,  153 
Facial  hemiatrophy,  354 
Fades  leonina,  583 
Factitious  urticaria,  49 
Farcy,  591 
Fatty  bodies,  716 
Favus,  420,  516 

alopecic,  421 

cutaneous,  114 

of  glabrous  skin,  518 

impetiginous,  421 

of  nails,  518 

pityriasic,  421 

squamous,  420 

treatment  of,  426 

urceolaris,  420 
Feigned  eruptions,  471 
Fetal  ichthyosis,  124 
Fetus,  harlequin,  124 
Fibroma,  689 

molluscum,  667 
Figured  eczematides,  92 
Filaria  medinensis,  514 
Filarial  elephantiasis,  361,  369,  515 
Filariasis,  369 
Fissured  eczema,  66 
Flat  angiomas,  693 

senile  warts,  208 

vascular  nevi,  693 

warts,  127 
Fleas,  506 

Flores  unguium,  438 
Fluxus  sebaceus,  384 
Follicles,  pilo-sebaceous,  376 
Folliclis,  398,  566 
Follicular  cysts,  671 

eczematides,  395 

ichthyosis,  403 

keratosis,  401,  403 

pustules,  160 

syphilides,  396 

tuberculides,  398 
Folliculite  conglomeree  en  placards,  382 

epilante,  394 
Folliculitides,  acute  suppurative,  377 

cicatricial  depilating,  392 

subacute,  395 

trichophytic,  380 
Folliculitis  agminata,  382,  522 

chancroidal,  597 

decalvans,  394 


Folliculitis  rubra,  402 
Folliculoses,  376,  377 
Forearms,  eczema  of,  75 
Fox,  Tilbury,  impetigo  of,  162 
Frambesia  Brasiliana,  650 

tropica,  250,  646 
Freckles,  323 

infective  melanotic,  665 
Frontal  scleroderma,  351 
Frost-bite,  34,  452,  564 

of  first  degree,  34 

of  second  degree,  34 
Fungoid  tuberculosis,  552 
Furfuracea,  409 
Furunculus,  540 

orientalis,  648 


Gafsa  boil,  648 
Gangrene,  buccal,  308 
carbolic,  314 
cutaneous,  312 
diabetic,  316 
direct  local,  313 
dry,  312 

fulminating,  of  genital  organs,  319 
moist,  312 

multiple,  of  adults,  318 
cachectic  of  skin,  317 
of  children,  317 
through  changes  in  blood,  316 
traumatic,  313 
of  vascular  origin,  315 
Gangrenous  dermatitis  of  children,  317 
ecthyma,  317 
erysipelas,  319 
pemphigus,  187 
urticaria,  317 
varicella,  171,  317 
Gastro-intestinal  purpura,  55 
Genital  chancre,  616 
diabetides,  480 
herpes,  310 

mucosa,  soft  chancre  of,  310 
syphilitic  chancre  of,  311 
traumatic  excoriations  of,  310 
tuberculous  ulcer  of,  311 
ulcerations  of,  310 
organs,  gangrene  of,  fulminating, 
319 
granuloma  of,  ulcerative,  251 
Genito-crural  zona,  156 
Geographical  tongue,  228 
Giant  chancre,  615 

urticaria,  49 
Gift-spots,  438 
Glanders,  590 
acute,  591 
chronic,  592 
mutilating,  of  face,  592 


758 


INDEX 


Glanders,  pustules  of,  173 

ulcerations  of,  293 
Glandular  lymphadenoma,  regional,  653 
Glossitis,  deep,  226 

exfoliativa  marginata,  228 

median  rhomboidal,  226 

of  nervous  arthritics,  228 
•  sclerotic,  226 

syphilitic.  225 
Glossodynia,  488 
Gluteal  erythema,  infantile,  31 
Glycerine,  715 
Glycosuric  xanthoma,  699 
Gonococcal  keratoderma,  216 

keratoma,  210 
Gonorrhea,  erosions  in,  310 
Gout,  tophi  of,  702 
Granuloma  annulare,  261 

favosum,  517 

fungoides,  657 

of  genital  organs,  ulcerative,  251 

inguinale,  251 

pyogenicum,  704 

trichophyticum,  522 

venereo,  251 
Granulosis  rubra  nasi,  443 
Green  cancer,  653 
Groin  ulceration,  251 
Ground-itch,  515 
Gummas,  266 

dermic,  267 

hypodermic,  267 

leprous,  272 

mycotic,  270 

scrofulo-tubercular,  268 

sporotrichotic,  270 

syphilitic,  267 

of  palatine  velum,  268 
of  tongue,  268 

tuberculous,  268,  550 
Gummous  infiltrations  of  leprosy,  272 
Gutta  rosea,  36 


Haihy  nevi,  668 

regions,  pruritus  of,  488 
Hamartoma,  359 
Hands,  eczema  of,  75 
Hang  nails,  432 
Harlequin  fetus,  124 
Head-lice,  502 
Heat-stroke,  32 
Hebra,  acne  varoliformis  of,  391 

eczema  marginatum  of,  524 
Hebra's  prurigo,  494 
Helconyxis,  437 
Hemangioma,  693 
Hematidrosis,  444 
Hematogenous  pruritus,  485,  487 
Hemiatrophy,  facial,  354 


Hemorrhagic  pemphigus,  187 

urticaria,  44 

zona,  155 
Hemosiderin,  320 
Herpes,  150 

buccal,  152,  304 

circinatus,  66,  114,  522 

conjunctivalis,  153 

cretaceus,  570 

genital,  150,  310 

gestationis,  184,  185 

iris,  176 

malignant,  122 

of  pharynx,  152 

progenitalis,  150 

recurrent,  153 

tonsurans  maculosus,  93,  99 

ulcerated,  284 

vacciniform,  168 

zoster,  154.     See  Zona. 
Herpetic  angina,  152 
Herpetide,  benign,  122 
Herpetiform  syphilides,  398 
Hidradenomata,  673 
Hidrocystoma,  672 
Hidrosadenitis,  446,  544 

suppurativa  disseminata,  566 
Hidroses,  441 

functional,  442 

organic,  445 
Hutchinson's  teeth,  628 
Hydradenitis    destruens    suppurativa, 

566 
Hydrargyria,  cutaneous,  465 
Hydroa,  25,  175 

Bazin's,  176 

buccal,  177,  304 

herpetiforme,  179 

puerporum,  185 

vacciniforme,  185 
Hyperchromia,  320 
Hyperidrosis,  442 

nudorum,  443 

oleosa,  443 
Hyperkeratoses,  194 

congenital,  203 
diffuse,  124 

ichthyosiform,  124,  203 
Hyperkeratotic  eczema,  64 

nevi,  206 

verrucose  nevi,  667 
Hypertrichoses,  404 

fetalis,  406 

regional,  407 
Hypertrophic  acne,  375 

chancre,  615 

dermatoses,  361 

lichen  corneus,  140,  247 

mucous  patches,  247 
Hypertrophies,  cutaneous,  360 

non-elephantiastic,  371 
Hypodermic  gummas,  267 


INDEX 


759 


Hypodermic  sarcoids,  273 
tubercles,  252 
tuberculides,  564 


Ichthyosiform  congenital  erythro- 
derma with  hyper-epidermatro- 
phy,  204 

erythroderma,  203 

hyperkeratosis,  124,  203,  205 
Ichthyosis,  200 

anserina  scrofulosorum,  402 

buccal,  219 

congenital,  124 

cornea,  200 

fetal,  124 

follicularis,  403 

hystrix,  202 

nitida,  202 

sauriasis,  205 

senile,  202 

tabescentium,  202 
Idiopathic  atrophies,  343,  344 

zona,  158 
Impetiginization,  64 
Impetiginous  eczema,  64,  71,  72 

favus,  421 

lupus,  556 

onyxis,  434 

stomatitis,  167 
Impetigo,  162 

of  Bockhardt,  167 

bullous,  168,  178 

contagiosa,  167 

figurata,  166 

granulata,  166 

herpetiformis,  185 

larvalis,  166 

miliary,  87 

of  mucous  membranes,  167 

sparsa,  166 

staphylococcic,  167 

streptococcic,  162 

of  Tilbury  Fox,  162 

vulgaris,  165 
Infantile  eczema,  65,  80 

gluteal  erythema,  31 

vacciniform  dermatitis,  168 
Infected  eczema,  64 
Infectious  dermatoses,  535 
bacillary,  546 
due  to  protozoa,  610 

urticaria,  46 
Intercostal  zona,  156 
Interstitial  vesiculation,  148 
Intertrigo,  30 
Intertrigo-eczema,  30 

of  infants,  75 
Intertrigo-erythema,  30 
Ioderma  bullosum,  177 


Ioderma  tuberosum,  476 
Iodide  acne,  475 

pemphigus,  475 
Iris,  herpes  of,  176 
Isolation,  32 
Itching,  481 
Ixodes,  514 

J 

Jadassohn,    anetoderma    erythemato- 

sum  of,  345 
Jigger,  506 
Juvenile  flat  warts,  130,  241 


"  Kartenblattaehnliche  morphoea," 

346 
Keloid  acne,  391 
Keloids,  690 
Keratoderma,  195,  211 

essential,  211 

familial,  211 

gonococcal,  216 

occupational,  213 

symmetrical,  of  adults,  212 

symptomatic,  213 
Keratodermic  syphilides,  619 
Keratoma,    diffuse    congenital    malig- 
nant, 124 

gonococcal,  210 

palmare  et  plantare,  211 
Keratosis,  194 

arsenical,  213 

circumscribed,  195,  206 

diffuse,  195 

follicular,  401,  403 

generalized,  195 

of  mucosae,  195 

of  mucous  membranes,  218 

pilaris  rubra  atrophicans  of  face, 
402 
simplex,  402 

punctiform,  216 

regional,  195 

senilis,  209 
Keratotic  eczema,  72 

nevi,  206 
Kerion  of  Celsius,  382,  522 
Kerosis,  37,  196 
Kerotic  alopecias,  408 
Koch's  phenomenon,  548 
Koilonychia,  437 
Kraurosis  vulvae,  354 


Lamellar  desquamation  of  newborn, 
122 
eczema,  64 
Lanuginous  pseudohypertrichosis,  406 


760 


1XDEX 


Larva  migrans,  515 
Lazarine  leprosy,  58(5 
Legs,  eczema  of,  75 

varicose  ulcers  of,  296 
Leishmanioses,  648 
Lenticular  papular  syphilides,  129,  142 

syphilides,  til!) 
Lentigines,  665 
Lentiginosis  profusa,  665 
Lentigo,  665 

maligna,  665 
Leontiasis,  365 

leprosa,  583 
Lepra  maculosa,  585 

nervorum,  585 

tuberosum,  583 
Leprides,  581,  588 
Lepromas,  258 
Lepromata,  587 
Leprosy,  578 

dyschromias  of,  327 

gummous  infiltrations  of,  272 

lazarine,  586 

mixed  form  of,  587 

morpha?  of,  332 

"rat,"  579 

tubercles  of,  258 

tubercular,  583 

ulcerations  of,  292 
Leprous  gummas,  272 

infiltrations,  258 

morphea,  258 

nodosities,  271 
Leptothrix  of  Wilson,  428 
Leptus  autumnalis,  513 
Leuconychia,  438,  653 
Leukemia,  cutaneous,  651 

lymphatic,  651,  652 

myeloid,  651,  652 

treatment  of,  661 
Leukemic  erythroderma,  119 
Leukoderma,  321,  331 
Leukokeratosis,  219 
Leukomelanodermas,  331,  332 
Leukonychia  totalis,  438 
Leukoplakia,  219 

and  cancer,  221 

ulcerations  of,  307 

vulvar,  220 
Leukotrichia,  416 
Lichen,  acute,  134 

annulatus,  133 

serpiginosus,  90 

circumscriptus,  90 

corneus,  hypertrophic,  140,  247 

ferox,  polymorphous,  495 

gyratus,  90 

marginatus  seu  serpiginosus,  133 

nitidus,  564 

pilaris,  402 

planus,  131 
acute,  120 


Lichen  planus,  atrophic,   137,  332,  339 
moniliformis,  139 
of  mucous  membranes,  227 
nitidus,  138 
obtusus,  139 
sclerotic,  137 

scleroticus  vel  atrophicus,  463 
treatment  of,  136 
verrucosus,  140 
psoriasis,  112 
rubra  acuminatus,  399 
bullosus,  134 
planus,  131 
scrofulosorum,  145,  564 
simplex,  492,  498 
spinulosus,  403 
striatus,  133 
urticus,  492 
Wilson's,  131 
zoniformis,  133 
Lichenified  eczema,  71,  72 
Lichenization,  490 
Lichenoid  eczema,  64 
syphilides,  396 

trichophytosis,  disseminated,  522 
tuberculide,  146,  564 
Linear  atrophies,  341 

nevi,  206 
Lipoma,  691 
Livedo,  36 

annularis,  26,  36 
Liver  spots,  664 
Lobular  epithelioma,  676 
Lues  venerea,  610 
Lumbo-abdominal  zona,  156 
Lupoid  acne,  394 

sycosis  of  Brocq,  394 
Lupoids,  272 
benign,  259 

disseminated  miliary,  259 
nodular,  260 
tubercles,  259 
Lupoma,  553 
Lupus,  553 

acneiform,  570 
agminatus,  554 
angiomatous,  554 
colloid,  554 
confluens,  554 
diffusus,  554 
disseminatus,  554 
elephantiastic,  554 
elevatus,  554 
erythematodes,  228,  568 
discoides,  570 
disseminatus,  566 
exanthematicus,  564,  572 
migrans,  571 
treatment  of,  573 
erythematoid,  554 
erythemato-follicular,  570 
erythemato-tuberculous,  555 


Index 


761 


Lupus  exedens,  555 

hypertrophicus,  554 

impetiginous,  556 

macular,  554 

non-exedens,  554 

papillomatous,  554 

phagedenicus,  555 

planus,  554 

psoriatiform,  554 

pustular,  173,  555 

resolutus,  554 

scleroticus,  554 

serpiginous,  555 

squamous,  554 

treatment  of,  561 

tubercle,  553 

tumidus,  554 

ulcerations,  290 

ulcerative  vegetative,  555 

vorax,  555 

vulgaris,  553 
Lymphadenia,  cutaneous,  657 
Lymphadenoma,    regional    glandular, 

653 
Lymphangiectases,  696 
Lymphangioma,  695 
Lymphangitis,      sporotrichotic      gum- 
mous,  270 

tuberculous  gummous,  269 
Lymphatic  leukemia,  651 

varicosities,  696 
Lymphoderma  perniciosa,  119 
Lymphogranulomatosis,  653 
Lymphorrhea,  362 
Lymphosarcoma,  653 
Lymph-scrotum,  363 


Microglossia,  congenital,  370 
Macular  atrophies,  341 
Macules,  23,  322 
Madura  foot,  270,  602 
Madurella,  599 
Mai  del  Pinto,  528 
Malassezia  furfur,  529 
Malgache,  301 
Malignant  edema,  594 

pustule,  593 
Malleus,  590 
Malum  perforans,  302 
of  mouth,  308 
plantaris,  303 
Mechanical  purpura,  54 
Medicinal  acne,  390 

eruptions,  463,  472 

roseola,  25 
Meige,  trophedema  of,  371 
Melanin,  320 
Melanodermas,  325 

Addisonian,  325 


Melanodermas,  pediculous,  329 

phthiriasic,  329 

tuberculous,  325 
Melanosis  lenticularis  progressiva,  355 

precancerous  circumscribed,  665 

progressive  cutaneous,  665 
Meleda  disease,  271 
Mendacia,  438 
Mercurial  stomatitis,  308 
Microbic  eczema,  66 
Microsporia,  527 
Microsporon  Audouini,  527 

furfur,  530 

minutissimum,  532,  533 
Microsporosis,  114 
Miliaria  crystallina,  445 
Miliary  abscess  of  little  children,  446 

colloid  degeneration  of  cutis,  359 

impetigo,  87 

syphilides,  619 

tuberculosis  of  skin  and  mucous 
membranes,  549 
Milium,  385,  671 
Milks,  717 

Moist  erosions  of  buccal  mucosa,  304 
Molluscum  contagiosum,  674 

pendulum,  667 
Monilithrix,  418 
Morbus  maculosus,  57 
Morphse  gutta,  346 

of  leprosy,  332 

nostras,  332 
Morphea,  350 

leprosa,  582 
Morphology    of    the    dermatoses,    17, 

23 
Mosquitoes,  507 
Mouth,  herpes  of,  153 

malum  perforans  of,  308 

syphilitic  chancres  of,  307 

"trench,"  306 

ulcers  of,  trophic,  308 
Mozambique  ulcers,  301 
Mucous  membranes,  impetigo  of,  167 
keratosis  of,  218 
lichen  planus  of,  227 
lupus  of,  558 
ulcerations  of,  303 
zona  of,  157 

patches,  144,  620 

hypertrophic,  247 
Muguet,  305 
Mycetoma,  270,  602 
Mycoses,  papillomatous,  249 
Mycosis  fungoides,  657 
Mycotic  gummas,  270 
Myeloid  leukemia,  651 
Myelomatosis,  652 
Myoma,  692 
Mythomania,  193 
Myxedema,  372 
Myxoma,  692 


762 


INDEX 


N 


Nail,  epidermic,  431 
Nail-plate,  430 

Nails,    congenital     malformations    of, 
431 

diseases  of  the,  430 

eczema  of,  435 

hang,  432 

worn-off,  432 
Nasal  pruritus,  488 
"  Necklace  of  Venus,"  326 
Necrobiosis,  312 
Necrosis,  312 
Neoplasms  of  buccal  cavity,  ulcerative, 

309 
Nervous  diseases,  dyschromias  of,  327 

pruritus,  485,  487 
Neuro-arthritic      pseudo-elephantiasis, 
371 

pseudolipoma,  371 
Neurodermatoses,  481 
Neuro-fibromatosis,  668 
Neuromas,  plexiform,  667 
Nevi,  664 

achromic,  320 

adenomatous,  672 

cellular,  666 

cystic  follicular  adenomatous,  671 

hairy,  668 

hyperkeratotic,  206 

keratotic,  206 

linear,  206 

molluscum,  667 

pigmentary,  665 

pilosi,  405 

tuberous,  non-vascular,  666 

varicose,  206 

vascular,  23,  693 

verrucose,  666,  667 
Nevo-carcinomata,  667,  682 
Nevo-cellular  epitheliomas,  682 
Newborn,  erythrodermas  of,  122 

lamellar  desquamation  of,  122 
Nile  boil,  648 
Nipple,  eczema  of,  75 

Paget's  disease  of,  234 
Nits,  502 
Nocardia,  599 
Nodes,  263 

subacute  non-gummous,  271 
Nodular  dermatoses,  263,  265 

erythema,  24 

lupoid,  260 

syphilides,  271 
Nodules,  263 
Noma,  308 

Non-cicatricial  alopecias,  412 
Non-elephantiastic  hypertrophies,  371 
Nosology  of  the  dermatoses,  447 
Nummular  eczema,  72 

syphilides,  619 


Nurslings,    desquamative    erythroder- 
ma of,  124 
exfoliative  dermatitis  of,  123 


Occlusive  dressings,  717 
Occupational  acne,  390 

dermatitides,  467 

eczema,  65,  467 

keratoderma,  213 

radiodermatitides,  454 
Oidium,  599 
One-year  boil,  648 
Onychogryphosis,  431,  43S 
Onychophagia,  432 
Onychomycosis,  433 

favosa,  433 

trichophytica,  433,  522 
Onychorrhexis,  439 
Onychoschizia,  439 
Onychoses,  430 

of  the  dermatoses,  434 

dystrophic,  437 

of  general  diseases,  436 

of  nervous  origin,  437 

traumatic,  432 
Onyxis,  impetiginous,  434 

pyococcic,  434 

syphilitic,  436 
Opaline  plaques,  620 
Ophiasis,  413 
Ophthalmic  zona,  156 
Orbicular  eczema,  75 
Oriental  boil,  250,  648 
Orificial  eczema,  75 
Oroya  fever,  593 


Pachydermatocele,  372 
Pachydermic  cachexia,  372 
Pachyonyxis,  437 
Pagetoid  epithelioma,  681 
Paget's  disease  of  nipple,  234 
Palatine  velum,  svphilitic  gummas  of 

268 
Palmar  pruritus,  488 

psoriasis,  215 

syphilides,  psoriatiform,  216 

trichophytosis,  216 
Paludean  pigment,  320 
Panighao,  515 
Papillary  dystrophy,  242 

epithelioma,  677 
Papillomata,  670 
Papillomatous  dermatoses,  238 

elephantiasis,  246 

epithelioma,  249 

lupus,  554 


INDEX 


763 


Papillomatous  mycoses,  249 

sporotrichoses,  249 

toxicodermas,  249 

tuberculosis,  247 
Papular  chancre,  615 

dermatoses,  127 

erythema,  24 

patches,  127 

plaques,  127 

roseola,  142 

syphilides,  142,  619 

urticaria,  45 
Papules,  127 

dermic,  128 

epidermic,  127 

mixed,  129 

of  prurigo,  140,  141 

of  strophulus,  141 
Papulo-circinate  syphilide,  144 
Papulo-erythematous  erythema,  39 
Papulo-lenticular  erythema,  37 
Papulo-ne  erotic  tuberculides,  398,  566 
Papulo-nummular  syphilides,  144 
Papulo-pustular  follicular  syphilides,398 
Papulo-pustules,  160 
Papulo-squamous  follicular  syphilides, 
397 

syphilide,  142 

tuberculide,  147 
Papulo-tubercles,  252 
Papulo-vesicular  eczema,  72 
Paraffinoma,  276 
Parakeratosis,  64 

variegata,  112 
Parapsoriasis,  111 

guttata,  111 

lichenoides,  111 

in  plaques,  112 
Parapsoriatic  tuberculides,  564 
Parasites,  animal,  502 

vegetable,  502 
Parasitic  dermatoses,  502 

eczema,  65 

trichoses,  419 
Parasitophobia,  482 
Paratraumatic  eczema,  66,  73 
Parchment-like  scleroderma,  346 
Parenchymatous  vesiculation,  148 
Pastes,  717 

Pathogenic  erythema  of  Bazin,  27 
Pathomania,  193 
Pediculoides  ventricosus,  514 
Pediculosis,  502 
Pediculous  melanoderma,  329 
Pediculus  pubis,  505 
Pellagra,  32 
Pemphigus  acutus  febrilis  gravis,  179 

chlorotic,  192 

chronic,  186,  188 

congenital,  191 

with  tendency  to  cicatrization 
191 


Pemphigus  diphtheroid,  187 
epidermic,  of  newborn,  168 
foliaceus,  120,  189 
gangrenous,  187 
hemorrhagic,  187 
hystericus,  192 
iodide,  475 
pruriginous,  179 
recurrent,  179 

simple  traumatic  hereditary,  191 
successif  a  Kystes  epidermiques, 

191 
syphilitic,  177 
treatment  of,  189 
ulcerative,  187 
vegetans,  244,  245 
virginal,  192 
vulgaris,  186 
with  small  bullae,  179 
Peribuccal  pruritus,  488 
Perigenital  pruritus,  488 
Perionyxis,  435 
Peripheral  zona,  156 
Peripilar  eczematides,  95 

seborrheids,  395 
Perleche,  540 

Phagedena,  chancroidal,  295 
tertiary,  295 
ulcerations  of,  293 
Phagedenic  ulcers,  281 

of  tropical  countries,  301 
Pharynx,  herpes  of,  152 
Phlegmonous  acne,  386 
hidrosadenitis,  446 
Phlyctenoses,  recurrent,  of  extremities, 

186 
Phthiriasic  melanoderma,  329 
Phthiriasis,  502 
Phthirius  inguinalis,  505 
Phthisis,  acute  buccal,  289 
Pian,  646 
Pian-Bois,  649 
Piedra,  428 
Pigeonneau,  469 

Pigmentary  dermatosis  of  legs,  323 

dystrophy,  242 

spots,  323,  325 

syphilides,  326 

Pigmentations,  artificial,  321 

Pigmented  erythema,  24 

urticaria,  44 
Pigments,  cutaneous,  320 
Pilo-sebaceous  follicles,  376 
Pinta,  528 

Pityriasic   erythroderma  in   dissemin- 
ated patches,   173 
favus,  421 
Pityriasiform  eczematides,  93 
Pityriasis  capitis,  198 
circinata,  90 

lichenoides  chronica,  112 
maculata  et  circinata,  99 


764 


INDEX 


Pityriasis  oleosa,  199 
.     rosea,  99,  198 

rubra,  118,  198 

pilaris,  120,  198,  399,  564 

sicca,  199 

simplex,  147,  198 

of  face  and  hairless  parts,  200 

versicolor,  198,  529 
Pityroid  alopecias,  409 
Plantar  pruritus,  488 

psoriasis,  215 

syphilides,  psoriatiform,  216 

trichophytosis,  216 

warts,  241 
Plexiform  neuromas,  667 
Plica,  503 
Poikiloderma    vascularis    atrophicans, 

344 
Polyadenomas,  676 
Polymorphous  acne,  386 

dermatitis,  179 

erythema,  bullous,  175 
Porokeratosis,  210,  216 
Port-wine  stains,  664,  693 
Posterosive  syphiloid,  31 
Postsyphilitic  atrophies,  342 
Powders,  714 
Pox,  610 

Precancerous  affections,  236,  685 
Premycotic  erythroderma,  119 
Presenile  dystrophy,  358 
Progressive  multiple  angiomas,  694 
Proliferating  dermatoses,  accidentally, 
244 

epithelioma,  249 

pyodermatitides,  246 

tropical  dermatoses,  249 
Prurigenetic  mnemoderma,  485 

summation,  485 
Pruriginous  pemphigus,  179 
Prurigo,  488 

circumscripta,  498 

ferox,  495 

Hebra's,  494 

hiemalis,  497 

lymphadenique,  495 

nodularis,  495 

papules  of,  140,  141 

simplex  acutus,  492 

summer,  498 

treatment  of,  499 

vulgaris,  496 
Pruritus,  anal,  488 

artificial,  482 

biopsic,  487 

buccal,  488 

diathetic,  484 

dyscratic,  484,  487 

of  hairy  regions,  488 

hematogenous,  485,  487 

hiemalis,  484 

localized,  488 


Pruritus,  nasal,  488 

nervous,  485,  487 

palmar,  488 

peribuccal,  488 

perigenital,  488 

primary,  483 

plantar,  488 

secondary,  482 

senile,  488 

toxic,  484 

treatment  of,  499 

vulvar,  488 

winter,  484 
Pseudococcidias,  231 
Pseudo-elephantiasis,     neuro-arthritic, 

371 
Pseudolipoma,  neuro-arthritic,  371 
Pseudo-pelade  of  Brocq,  393 
Pseudoxanthoma  elasticum,  358 
Psoriasis,  102 

arthropathia  105 

buccal,  219 

discoides,  102 

dolorosa,  105 

guttata,  102 

infiltrated,  104 

inversa,  105 

inveterata,  104 

lichen,  112 

nummularis,  102 

oozing,  104 

palmar,  215 

plantar,  215 

punctata,  102 

syphilitic,  216 

treatment  of,  109 

universalis,  120 
Psoriatiform  eczema,  64 

eczematides,  95 

lupus,  554 

syphilides,  113,  216 
Psorospermosis    follicularis    vegetans, 

231 
Pulex  penetrans,  506 
Punctiform  keratosis,  216 
Purpura,  52 

of  acute  infectious  diseases,  54 

annularis  telangiectodes,  56 

cachectic,  54 

exanthemata,  55 

fulminans,  57,  317 

gastro-intestinal,  55 

hemorrhagica,  53,  57 

mechanical,  54 

primary,  54,  75 

rheumatoid,  54 

secondary,  54 

senilis,  54 

simplex,  53 

toxic,  54 

urticans,  44 
Purpuric  erythema,  24 


INDEX 


765 


Purpuric  fever,  59 
Pustular  dermatoses,  161 

lupus,  173,  555 
Pustules,  160 

dermic,  160 

epidermic,  160 

follicular,  160 

of  infectious   chronic  dermatoses, 
172 
Pyococci,  536 
Pyococcic  onyxis,  434 
Pyodermatitides,  467,  536 

proliferating,  246 


Radiodermatitides,  452 

"Rat  leprosy,"  579 

Recklinghausen's  disease,  668 

Recurrent  pemphigus,  179 

Red  tongue,  228 

Reducing  agents,  734 

Reflex  erythema,  28 

Regional  glandular  lymphadenoma,  653 

Reticular  atrophy,  344 

Rheumatic  nodosities,  266 

Rheumatoid  purpura,  54 

Rhinophyma,  374 

Rhinoscleroma,  373 

Rhomboidal  glossitis,  median,  226 

Rodent  ulcer,  281,  682 

Rosacea,  36 

Roseola,  antipyrin,  42 

balsamic,  42 

emotional,  25 

of  leprosy,  42 

medicinal,  25 

of  mycosis  fungoides,  42 

papular,  142 

squamosa,  99 

symptomatic  infectious,  25 

syphilitic,  41 
Roseolar  exanthematic  fevers,  25 
Rouget,  513 

Rubeoliform  erythema,  25 
"Run-around,"  163 


S 


Saccharomyces,  599 
Salek  boil,  648 
Salve  sticks,  716 
Salves,  716 
Sarcoids,  259,  272 

benign,  259,  272,  564 

disseminated  nodular,  273,  564 

hypodermic,  273 

subcutaneous,  564 
Sarcoma,  706 

atypical,  706,  708 


Sarcoma,  fascicular,  706 

generalized,  707 

multiple  hemorrhagic,  709 

primary  idiopathic,  706 

round-cell,  706,  707 

secondary  metastatic,  706 

spindle-cell,  706 

typical,  706 
Scabies,  507 

animal,  512 

equine,  120,  512 

Norwegica,  512 
Scabitees  ungium,  437 
Scaborrhea,  fatty,  383 
Scalp,  eczema  of,  74 
Scarlatiniform  erythema,  25 

recurrent  desquamative,  25 
Sclerema,  347 
Sclerodactylia,  348 
Scleroderma,  347 

annular,  352 

in  bands,  351 

edematous,  347 

frontal,  351 

generalized,  347 

parchment-like,  346 

partial,  350 

in  patches,  350 

progressive,  348 

superficial  circumscribed,  346 
Sclero-gummous  ulcerations,  288 
Scleronychia,  431 
Sclerosis,  cutaneous,  334 
Sclerotic  atrophies  in  spots,  346 

dermatoses,  335 

lichen  planus,  137 
Scrofuloderma,  268 
Scrofulo-tubercular  gummas,  268 
Scrofulous  ecthyma,  170 
Scrotal  tongue,  226 
Scurvy,  infantile,  55 

sporadic,  55 
Sebaceous  cysts,  670 

flux,  383 
Seborrhea,  383 

congestiva,  570 

corporis,  90 

sicca,  198 

steatosa,  383 
Seborrheal  eczema,  63 

syphilides,  144 

warts,  208 
Seborrheic  alopecias,  409 

cocoon,  383 

filament,  383 

oleosa,  384 

utriculus,  383 
Seborrhoids,  91 
Senile  degeneration,  357 

eczema,  65 

pruritus,  488 

purpura,  54 


766 


INDEX 


Senile  warts,  flat,  208 
Serous  cysts,  672 
Serpiginous  lupus,  555 
Serum  eruptions,  477 
Slough,  312 

Smooth  patches  of  tongue,  228 
Soapy  salves,  717 
Soft  chancre,  596 

verrucose  nevi,  666 

warts,  666 
Solutions,  714 
Soor,  305 
Sphacelus,  312 

Spinocellular  epithelioma,  676 
Spirochete  pallida,  610 
Sporotrichium,  599 
Sporotrichoses,  605 

papillomatous,  249 
Sporotrichotic  gummas,  270 

gummous  lymphangitis,  270 
Squamous  eczema,  64,  72 

erythema,  24 
Staphylococci,  536 
Staphylococcic  impetigo,  167 
Steatorrhea,  383 
Stellate  angioma,  695 
Stimulants  and  rubefacients,  742 
Stomatitis,  diphtheroid,  305 

impetiginous,  167 

mercurial,  308 

ulcero-membranous,  306 

Vincent's,  306 
Streptococci,  536 
Streptococcic  impetigo,  162 
Strophulus,  45,  492 

papules  of,  141 
Sudamina,  445 
Sudoriparous  abscesses,  446 
Sulcated  tongue,  226 
Summer  eruption,  185 

prurigo,  498 
Sunburn,  32 
Sweat,  441 
Sweats,  colored,  444 
Sycosis,  378 

of  beard,  379 

on  hairy  scalp,  379 

lupoid,  of  Brocq,  394 

of  mustache,  379 

simplex,  378 

treatment  of,  380 

trichophytica,  522 
barbae,  380 
Symmetrical    keratoderma    of    adults, 

212 
Symptomatic  infectious  roseola,  25 
Syphilides,  613 

acneiform,  398 
peripilar,  396 

annular,  144 

arciform,  144 

bullous,  177,  620 


Syphilides,  corymbiform,  398 

en  bouquets,  398 

erythemato-papular,  142 

erythematous,  620 

follicular,  396 

granular,  396 

herpetiform,  398 

keratodermic,  619 

lenticular,  129,  142,  619 

lichenoid,  396 

miliary,  396,  619 

nigricantes,  143,  322 

nodular,  271 

nummular,  619 

papular,  142,  619 

papulo-circinate,  144 

papulo-nummular,  144 

papulo-squamous,  142 

pigmentary,  326 

psoriatiform,  216 

seborrheal,  144 

secondary,  619 

of  mucosa,  620 

tertiary,  622 

tubercular,  253 

tuberculo-gummous,  285 

tuberculo-ulcerative,  285 

ulcerative,  284,  285,  620 

varicelliform,  390 

varioliform,  398 
Syphilis,  610 

acquired,  612 

congenita  tarda,  627 

congenital,  624 

precocious,  625 

experimental,  612 

insontium,  616 

maligna  precox,  284 

pustules  of,  172 

treatment  of,  632 

ulcerations  of,  284 
Syphilitic  alopecias,  411 

bubo,  612 

chancre,  613 

of  genital  mucosa,  311 
of  mouth,  307 
ulcerative,  283 

ecthyma,  170 

glossitis,  225 

gummas,  267 

of  palatine  velum,  268 
of  tongue,  268 

leukomelanodermas,  332 

onyxis,  436 

patches,  144 

pemphigus,  177 

psoriasis,  216 

roseola,  41 

rupia,  170,  285 

ulcerations,  285 
Syphiloid,  posterosive,  37 
Syringocystadenoma,  673 


INDEX 


767 


Tattoo  marks,  332 
Teeth,  Hutchinson's,  628 
Tertiary  phagedena,  295 

syphilides,  622 
Therapeutic  notes,  711 

radiodermatitides,  453 
Thrush,  305 
Ticks,  514 
Tinea  acuminatum,  424 

crateriforme,  424 

favosa,  420 

imbricata,  528 

microsporica,  421 

tonsurans,  420 

tricophytica,  424,  522 

with  large  spores,  424 
Tineas,  419 
Tokelau,  528 
Tongue,  black,  229 
hairy,  229 

epithelioma  of,  221 

erosions  of,  304 

excoriation  of,  chronic  superficial, 
229 

geographical,  228 

leukoplakia  of,  219 

plaques  of,  depapillated,  304 

red,  228 

scrotal,  226 

smooth  patches  of,  228 

sulcated,  226 

syphilitic  gummas  of,  268 

villous,  229 
Tophi  of  gout,  702 
Toxic  eruptions  of  internal  origin,  472 

pruritus,  484 

purpura,  54 
Toxicodermas,  bullous,  177 

papillomatous,  249 
Toxidermas,  456 

from  internal  causes,  471 
Toxi-tuberculides,  565 
Traumatic  alopecias,  408 

bull®,  175 

eczema,  65 

eczematiform  dermatitides,  80 

excoriations  of  genital  mucosa,  310 

gangrene,  313 

onychoses,  432 
Trench  foot,  35 

mouth,  306 
Treponema  pallidum,  610 
Trichoma,  503 
Trichomycoses,  428 
Trichophytic  folliculitides,  380 
Trichophytine,  521 
Trichophyton  concentricum,  528 
Trichophytons,  520 
Trichophytosis,  519 

disseminated  lichenoid,  522 


Trichophytosis  of  hairless  skin,  522 

palmar,  216 

plantar,  216 

of  smooth  skin,  114 
Trichoptilosis,  418 
Trichorrhexia  nodosa,  417 
Trichoses,  404 

dystrophic,  416 

parasitic,  419 
Trichosporosis  nodularis  tropicalis,  428 
Trichotillomania,  408 
Trophedema  of  Meige,  371 
Trophic  ulcers  of  mouth,  308 
Trophoneurosis  facialis,  354 
Tropical  dermatoses,  proliferating,  249 

epidermomycoses,  114,  528 

ulcers,  307 
Tubercle,  anatomical,  552 

lupus,  553 
Tubercles,  252 

hypodermic,  252 

of  leprosy,  258 

leprous,  587 

lupoid,  259 

lupus,  256 
Tubercular  leprosy,  583 

syphilides,  253 

ulcer,  288 

fissured,  289 
of  genital  mucosa,  311 
papillomatous,  289 
Tuberculides,  563 

acneiform,  564 

angiokeratotic,  564 

eczematoid,  564 

erythemato-atrophic,  564 

erythematous,  564 

erythrodermic,  564 

follicular,  398 

hypodermic,  564 

lichenoid,  564 

lupoid,  564 

papulo-necrotic,  566 

parapsoriatic,  564 

pernio,  571 

ulcerated,  291 
Tuberculo-gummous  syphilides,  285 
Tuberculo-pustules,  160 
i  Tuberculo-ulcerative  dermatoses,  253 

syphilides,  285 
Tuberculosis,  546 

frambesiformis,  552 

fungoid,  552 

lymphangitic,  553 

fungosa  serpiginosa,  553 

luposa,  553 

miliary,  of  skin  and  mucous  mem- 
branes, 549 

papillomatous,  247 

pustules  of,  172 

ulcerations  of,  288 

vegetative,  552 


768 


INDEX 


Tuberculosis,  verrucous,  247,  550 
Tuberculous  dermatitis,  acute,  549 

gummas,  268,  550 

gummous  lymphangitis,  209 

lymphangitides,  553 

melanodermas,  325 

ulcer,  291,  549 
Tuberous  abscesses  of  axilla,  544 

angiomas,  093 

non-vascular  nevi,  000 
Tubular  epithelioma,  079,  082 
Tumors,  calcareous,  092 

connective-tissue,  089 

epithelial,  009 

vascular,  089 
Tylosis,  essential,  212 

linguae,  219 
Tylotic  eczema,  72 
Typhus,  angiohematic,  57 


Ulcer,  rodent,  281,  082 

tuberculous,  549 
Ulcerated  gummous  infiltration,  288 

herpes,  284 

tuberculides,  290 
Ulcerations,  277 

acute,  281 

of  buccal  mucosa,  304 

chronic,  287 

of  dermatomycosis,  293 

of  genital  mucosa,  310 

of  glanders,  293 

groin,  251 

of  leprosy,  292 

of  leukoplakia,  307 

lupus,  290 

of  mucous  membrane,  281,  303 

of  phagedena,  293 

sclero-gummous,  288 

subacute,  284 

syphilitic,  284,  285 
gummous,  287 

tuberculous,  288 
Ulcerative  chancre,  015 

dermatoses,  281 

granuloma  of  genital  organs,  251 

neoplasms  of  buccal  cavity,  309 

pemphigus,  187 

syphilides,  020 

secondary,  284 

syphilitic  chancre,  283 

tertiary  syphilides,  285 

vegetative  lupus,  555 
Ulcero-membranous  stomatitis,  300 
Ulcers,  290 

Annamite,  301 

erosive,  070 

of  mouth,  trophic,  308 

Mozambique,  301 


Ulcers,  phagedenic,  281 

of  tropical  countries,  301 

simple,  290 

tropical,  301 

true,  281 

varicose,  of  leg,  290 
Ulcus  cruris,  290 

durum,  013 

epitheliomatosum  terebrans,  281 

molle,  590 
Ulerythema  centrifugum,  509 

ophryogenes,  402 

sycosiforme,  394 
Urticaria,  43 

ab  ingestis,  40 

accidental,  45 

acute,  45 

autotoxic,  40 

bullous,  45,  175 

chronic,  45 

factitious,  49 

gangrenous,  317 

giant,  49 

hemorrhagic,  44 

infectious,  40 

papular,  45 

perstans,  45 

pigmented,  44 

pigmentosa,  703 

treatment  of,  48 
Urticarial  erythema,  24 

fever,  44 
Urticarism,  43 


Vacciniform  dermatitis,  infantile,  108 

herpes,  108 
Vagabond's  disease,  329 
Varicella,  gangrenous,  171,  317 
Varicelliform  syphilides,  398 
Varicose  eczema,  73 

nevi,  200 

ulcer  of  leg,  290 
Varicosities,  lymphatic,  090 
Varioliform  syphilides,  398 
Vascular  nevi,  23,  093 

tumors,  089 
Vegetative  tuberculosis,  552 
Venereal  warts,  238 
Verruca  necrogenica,  552 

vulgaris,  240 
Verrucose  nevi,  000,  007 
Verrocosities,  237 
Verrucous  elephantiasis,  240 

excrescences,  237 

tuberculosis,  247 
Verruga  Peruana,  593 
Vesicles,  148 
Vesico-pustules,  100 
Vesicular  dermatoses,  149 


INDEX 


769 


Vesicular  eczema,  71 

erythema,  24 
Vespertilio,  571 
Vibices,  52 
Vincent's  angina,  306 

stomatitis,  306 
Virginal  pemphigus,  192 
Vitiligo,  329 

gravior,  582 
Vulvar  pruritus,  488 
Vulvar  leukoplakia,  220 


W 


War  wounds,  eczema  of,  66,  73 
Warts,    common,    240.     See    Verruca 
vulgaris. 

flat,  127 

juvenile  130,  241 
senile,  208 

plantar,  241 

seborrheal,  208 

soft,  666 

venereal,  238 
Watery  pastes,  715 

solutions,  714 
Weeping  eczema,  63 
Wens,  671 
Wheals,  43 
White  spot  disease,  346 

spots  of  smokers,  219 
Whitlow,  163 
Willan's  lupus,  553 
Wilson,  leptothrix  of,  428 
Wilson's  lichen,  131 
Winter  pruritus,  484 
Woody  phlegmon  of  aged,  544 


Worn-off  nails,  432 

Wounds,  war,  eczema  of,  66,  73 

Wrists,  eczema  of,  75 


Xanthelasma,  698 
Xanthochromia,  697 
Xantho-erythroderma  perstans,  113 
Xanthoma,  697 

congenital,  699 

diabetic,  699 

eruptive,  698 

glycosuric,  699 

pigmentosum,  355 

pilaris,  402 


Yaws,  250,  646 


Z 


Zona,  154 

buccal,  304 

cervical,  156 

chronic,  159 

genito-crural,  156 

hemorrhagic,  155 

idiopathic,  158 

intercostal,  156 

lumbo-abdominal,  156 

of  mucous  membrane,  157 

ophthalmic,  156 

peripheral,  156 

recurrent,  159 
Zoster  fever,  156 


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